Abstract
BACKGROUND: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are cornerstone therapies for heart failure, but their safety in extreme clinical scenarios warrants careful evaluation. CASE SUMMARY: A 37-year-old woman with end-stage familial hypertrophic cardiomyopathy and MYH7 mutations developed recurrent hypoglycemia during dapagliflozin therapy. Despite comprehensive guideline-directed therapy, progressive malnutrition (body mass index 18.4 kg/m(2)) and hypoglycemic episodes culminated in fatal hyperlactic acidemia and multiple organ failure. DISCUSSION: This case demonstrates SGLT2i may precipitate life-threatening hypoglycemia in nondiabetic, malnourished patients with advanced heart failure, particularly when superimposed on end-stage hypertrophic cardiomyopathy's metabolic vulnerability. TAKE-HOME MESSAGES: Enhanced vigilance and regular glucose monitoring are essential when using SGLT2i in high-risk populations. Unexplained hypoglycemia warrants immediate drug discontinuation in vulnerable patients.