Abstract
BACKGROUND: Pacemaker recipients are predisposed to heart failure (HF), yet evidence guiding preventive pharmacotherapy in this population remains unexplored. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have redefined HF management across a broad spectrum of cardiometabolic phenotypes. This study evaluated the association between SGLT2i therapy and clinical outcomes after pacemaker implantation for atrioventricular block. METHODS: Patients receiving conventional pacemakers between 2016 and 2024 were retrospectively analyzed and stratified by baseline SGLT2i therapy. Exclusions included sinus node dysfunction or iatrogenic pacing indications, single-chamber devices, and estimated glomerular filtration rate < 20 mL/min/1.73m(2). Events within 3 months post-implantation were omitted to reduce peri-procedural confounding. After propensity score matching, Cox regression assessed associations between SGLT2i use and all-cause mortality and HF hospitalization. RESULTS: Among 11,518 eligible patients, propensity score matching yielded two well-balanced cohorts of 1,226 SGLT2i users and non-SGLT2i users. Over three years, death occurred in 124 (10.1%) in the SGLT2i users and in 194 (15.8%) in the non-SGLT2i group (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.50 to 0.78; P < 0.001). HF hospitalization occurred in 132 (10.7%) in the SGLT2i group, and in 280 (22.8%) in the non-SGLT2i group (HR, 0.50; 95% CI, 0.41 to 0.62; P < 0.001). Subgroup analyses demonstrated consistent effects across strata. CONCLUSIONS: SGLT2i therapy was associated with reduced risk of all-cause mortality and HF-related hospitalizations following pacemaker implantation. Future randomized studies are needed to confirm this association.