Sodium-glucose co-transporter 2 inhibitor (SGLT2i) precursors were discovered in 1835 and glycosuric effects confirmed in 1886. Subsequently, there have been four paradigm shifts in the use of SGLTIs as eloquently summarised by Eugene Braunwald (1). These medicines reduced cardiovascular mortality and development of heart failure in patients with type 2 diabetes (T2DM) and cardiovascular disease (2–4). Additionally, similar benefits were seen in patients with heart failure (reduced and preserved ejection fraction), irrespective of diabetes, and in patients with chronic kidney disease (5–9). The benefits and optimal initiation of SGLTIs in patients with acute coronary syndrome (ACS) are still not proven. Could this represent the fifth paradigm shift in the use of SGLTIs?
