Abstract
Aims
Dapagliflozin, a sodium‐glucose cotransporter 2 (SGLT2) inhibitor, has shown clinical benefits in adults with heart failure (HF), improving cardiac function, reducing HF‐related hospitalizations and enhancing survival rates. While extensively studied in adult HF, data on its efficacy and safety in paediatric HF patients remain limited. We aimed to evaluate the use of dapagliflozin in addition to optimized therapy in paediatric HF patients regarding safety, clinical outcomes and adverse events.
Methods and results
We conducted a single‐centre retrospective analysis of 37 paediatric HF patients (median age 9.0 years, range 0.2–17.1 years) treated with dapagliflozin at our institution between April 2022 and February 2025. Clinical outcomes, left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), NT‐proBNP levels and estimated glomerular filtration rate (eGFR) were analysed at baseline, 3–6 months and the latest follow‐up. The most frequent diagnoses among paediatric HF patients treated with dapagliflozin were dilated cardiomyopathy (43.2%, 56% of those with acute myocarditis), heart transplant recipients (18.9%) and single ventricle heart defects (16.2%). The median duration of dapagliflozin treatment was 189 days (Q1, Q3: 381, 596). Dapagliflozin was well tolerated, with no severe adverse effects observed. During follow‐up, four patients required ventricular assist device (VAD) implantation, five underwent heart transplantation and one patient died. In six patients, the VAD could be explanted due to myocardial recovery. Overall, LVEF significantly improved from 40% at baseline to 51% at 3–6 months and further to 57% at latest follow‐up (P = 0.016). GLS significantly improved from −9.2% to −14.7% from baseline to latest follow‐up (P = 0.023). Heart failure classification significantly improved from baseline to latest follow‐up (P = 0.004). NT‐proBNP levels decreased during follow‐up, without reaching statistical significance.
Conclusions
Dapagliflozin in addition to optimized HF therapy was safe and well tolerated in paediatric HF patients, with improvements in functional class, left ventricular contractility and heart failure symptoms. The study's limitations, including its small sample size and retrospective design, highlight the need for larger, multicentre, prospective trials to confirm these findings.
Keywords: Dapagliflozin, Sodium‐glucose cotransporter 2 inhibitor, Paediatric heart failure
Introduction
Dapagliflozin is an oral sodium‐glucose cotransporter 2 (SGLT2) inhibitor, which was first used as an effective anti‐diabetic drug in patients with type 2 diabetes associated with improved glycaemic control and reductions in body mass and blood pressure. As patients with diabetes had improved cardiovascular and renal outcomes, SGLT2 inhibitors were then extended to patients with heart failure showing similar clinical benefits, although the underlying mechanisms are not clearly understood. Potential pathways of SGLT2 inhibitors include a reduction in sodium reabsorption and an increase in sodium delivery to the distal renal tubule, a downregulation in sympathetic activity and a decrease in the intraglomerular pressure, which may decrease preload and afterload in heart failure (HF) patients. More recently, novel mechanisms, such as reduction in epicardial fat, enhanced myocardial energetics and improved cardiomyocyte calcium handling have been suggested. 1 , 2
In adults with heart failure with reduced ejection fraction (HFrEF) and NYHA (New York Heart association) functional class II or higher, addition of SGLT2 inhibitors to optimized pharmacological and device therapy reduced the risk for hospitalization for HF and cardiovascular death. 3 , 4 Additionally, the annual decline in eGFR was decreased. 3 In adults with HF with mildly reduced ejection fraction (HFmrEF), SGLT2 inhibitor therapy was associated with a lower risk for HF hospitalization and a non‐significant decrease in cardiovascular deaths. 5 , 6 , 7 A meta‐analysis of patients of all HF types showed a significant reduction in mortality associated with dapagliflozin; however, this effect was less certain in patients with an LVEF of >44% and <51%. 8 In adults with heart failure with preserved ejection fraction (HFpEF) with volume overload (N‐terminal prohormone of B‐type natriuretic peptide, NT‐proBNP > 300 mg/mL), SGLT2 inhibitors reduced the risk for HF hospitalization whereas the effect on cardiovascular death is controversial between trials. 6 , 9 , 10 Limited data are available on the use of SGLT2 inhibitors in adults with congenital heart disease showing potential beneficial effects while they were generally well‐tolerated. 11
Data about the efficacy of SGLT2 inhibitors in paediatric heart failure patients are very limited to date. Newland et al. report that addition of dapagliflozin to guideline pharmacological therapy was well tolerated and showed a significant increase of left ventricular ejection fraction (LVEF) in a subpopulation of paediatric patients with dilated cardiomyopathy (DCM). 12 Additional studies, in particular, trials with larger paediatric patient cohorts, have not been published to date.
The aim of this study was to evaluate the use of dapagliflozin in paediatric HF patients at our institution with regard to safety, clinical outcomes and adverse events. We aimed to evaluate the use of dapagliflozin in addition to optimized therapy in paediatric HF patients regarding safety, clinical outcomes and adverse events.
Methods
Study design
This is a retrospective single‐centre analysis of all patients <18 years that were treated for HF symptoms at our institution and received the SGLT2‐inhibitor dapagliflozin. The study was approved by our institutional ethics committee (Decision No EA2/183/24) and conducted in accordance with institutional requirements and complies with the Declaration of Helsinki. Median age at the initiation of dapafliglozin was 9.0 years (Q1, Q3: 2.4, 12.8, range 0.2–17.1). Fifty‐one per cent were male. Children included in this study received 0.1–0.2 mg dapagliflozin once daily (maximum 10 mg). Clinical and echocardiographic parameters were analysed after 11 weeks to 6 months (the earliest examination was used for analysis if multiple were available) and from the latest follow‐up examination. The estimated glomerular filtration rate (eGFR) was calculated using the creatinine‐cystatin C‐based CKiD equation. 13 Absolute NT‐proBNP and age‐adjusted zlog‐NT‐proBNP levels, which can be interpreted as z‐scores, were used for analysis as described previously. 14 , 15 Left ventricular ejection fraction (LVEF) was measured biplane in the apical four and two chamber view, respectively, in 2D‐echocardiography. Global longitudinal strain (GLS) analysis was performed on three planes (four, two and three chamber view, respectively) and GLS was calculated by the vendor‐specific included software. Heart failure severity was assessed by the heart failure severity classification of the ISHLT, which combines the classification of the New York Heart Association (NYHA) with the modified Ross classification. 16 LVEF and GLS were only analysed in patients with biventricular anatomy without VAD support or on VAD support when pump stop examination was available for analysis. LVEF and GLS were not analysed in single ventricle heart disease (SVHD) patients, when a patient was put on VAD and no pump stop examination was available or when heart transplantation (HT) was performed during follow‐up. NT‐proBNP, GFR and NYHA/Ross class were only analysed in patients who neither received VAD implantation nor heart transplantation during follow‐up.
Statistical analysis
Categorical variables were described as absolute numbers with percentages and two‐tailed chi‐square test was performed for analysis. Data distribution was visualized by histogram and normality was tested with the Kolmorogov–Smirnov test. All variables displayed non‐normal distribution. Continuous variables are presented as median with quartiles Q1 and Q3. Wilcoxon rank test was performed for analysing repeated measurements of non‐parametric continuous variables at baseline and latest follow‐up only, because the overall sample size was small with a significant number of missing values limiting multiple comparison. A P‐value ≤ 0.05 was considered statistically significant. Data were analysed and plotted using SPSS statistics (version 23, IBM Corp., Armonk, NY, USA) and Prism Graph Pad 10 (GraphPad Software Inc., La Jolla, CA, USA).
Results
Patient characteristics
A total of 37 paediatric patients with HF symptoms received dapagliflozin between April 2022 and February 2025 at our institution. Figure 1 illustrates a significant increase in dapaglifozin therapy in paediatric patients at our institution from 2022 onwards. Patients' demographics are summarized in Table 1 . Median age at the start of dapafliglozin was 9 years (IQR 2.4–12.8). Fifty‐one per cent were male. The median follow‐up since initiation of dapagliflozin treatment was 189 days (Q1, Q3: 381, 596). Most patients (43.2%) were diagnosed with dilated cardiomyopathy (DCM), followed by paediatric heart transplant recipients (18.9%) and SVHD (16.2%). Of the SVHD patients three (60%) were failing Fontan patients. Of the patients with biventricular anatomy, 61.7% had systolic heart failure with a reduced or mildly reduced left ventricular ejection fraction. Eight patients were listed for a heart transplantation and four patients were on VAD support. Figure 2 illustrates the percentage of patients that were treated with the following heart failure drug classes: (1) angiotensin‐neprilysin inhibitor (ARNI), angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB); (2) mineralocorticoid antagonists (MRA); (3) beta‐blocker (BB) and (4) diuretics. Most patients were treated with ARNI/ACEI/ARB (94.6%) and MRA (91.9%). Beta‐blocker were used in 75.5% of all patients and diuretics in 67.6%. Medication is listed in Table 1 . A combination of four or more drugs as HF treatment was prescribed in 62.1%.
Figure 1.
Cumulative number of patients that were treated with SGLT2i at our institution showing a significant increase from 2022 onwards. SGLT2i, sodium‐glucose cotransporter 2 inhibitor.
Table 1.
Patient demographics
| Total (N = 37) | Median (Q1, Q3), N (%) |
|---|---|
| Dapagliflozin treatment (days) | 189 (381, 596) |
| Age at initiation of dapagliflozin (years) | 9 (2.4, 12.8) |
| <1 | 3 (8.1%) |
| 1–5 | 13 (35.1%) |
| 6–11 | 10 (27.0%) |
| 12–17 | 11 (29.7%) |
| Body weight (kg) | 25.8 (13.1, 49.8) |
| Sex | |
| Male | 19 (51.3%) |
| Female | 18 (48.7%) |
| Cardiac diagnosis | |
| Dilated cardiomyopathy (DCM) | 16 (43.2%) |
| DCM/Myocarditis | 9 (24.3%) |
| Previous heart transplantation/Cardiac allograft dysfunction | 7 (18.9%) |
| Single ventricle heart disease (SVHD) | 6 (16.2%) |
| Other | 6 (16.2%) |
| Systemic RV | 4 (%) |
| Heart failure type (SVHD excluded) | |
| HFpEF (LVEF ≥ 50%) | 8 (21.6%) |
| HFmrEF (LVEF 41%–49%) | 6 (16.2%) |
| HFrEF (LVEF ≤ 40%) | 17 (45.9%) |
| Listed for heart transplantation | 12 (32.4%) |
| VAD support at initiation of dapagliflozin | 6 (16.2%) |
| Heart failure medication | |
| MRA | 34 (92%) |
| Beta‐blocker | 28(76%) |
| ARNI | 25 (68%) |
| Thiazide diuretic | 21 (57%) |
| Loop diuretic | 14 (38%) |
| ACEi/ARB | 10 (27%) |
| Ivabradine | 9 (24%) |
| Levosimendan | 8 (22%) |
| Sildenafil | 5 (14%) |
ACEi, angiotensin converting enzyme inhibitor; ARB, angiotensin receptor blocker; ARNI, angiotensin‐neprilysin receptor inhibitors; DCM, dilated cardiomyopathy; HFmrEF, heart failure with mildly reduced ejection fraction; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; MRA, mineralocorticoid antagonists; SVHD, single ventricle heart disease; VAD, ventricular assist device.
Figure 2.
Heart failure medication and percentage of patients that were treated with it. ACEI, angiotensin converting enzyme receptor antagonist; ARNI, angiotensin receptor‐neprilysin inhibitor; ARB, angiotensin‐receptor blocker; BB, beta‐blocker; MRA, mineralocorticoid antagonist.
Therapy safety and adverse events
In general, dapagliflozin was well tolerated by all paediatric patients. One patient experienced a single episode of symptomatic hypoglycaemia a few days after initiation of dapagliflozin. She was ventilated and critically ill at that time and treated for systemic infection at the paediatric cardiac intensive care unit. No patient experienced significant electrolyte derangements, hypovolaemia or metabolic acidosis after initiation of SGLT2i therapy. One patient was treated for a balanitis with local anti‐inflammatory therapy 9 months after initiation of dapagliflozin treatment. We did not observe any antibiotically treated episodes of urinary tract infection during treatment with dapagliflozin. One patient experienced an episode of urine tract infection several weeks after dapagliflozin was discontinued. Dapagliflozin was not discontinued in any patient for adverse effects.
Clinical outcomes
Clinical outcome variables are listed in Table 2 . Six patients were on VAD support at the initiation of dapagliflozin and five patients had a VAD implanted during the follow‐up period (Figure 3 ). Six VAD‐supported children were bridged to recovery and one patient just prior to the initiation of dapagliflozin, and in four patients, the VAD was explanted during follow‐up. Five patients underwent a heart transplantation, and one patient died during the observation period. The patient was suffering from a progressive genetic limb‐girdle muscular dystrophy with DCM and was not eligible for heart transplantation and ultimately died of recurrent episodes of pneumonia. One patient was hospitalized at the latest follow‐up, whereas the others were discharged and followed in the outpatient department. Of the patients that were neither transplanted nor died during follow‐up (n = 30), 19 (63%) were still treated with dapagliflozin at the latest follow‐up whereas dapagliflozin was discontinued in seven patients (23%) due to recovery of cardiac function (five patients with acute/chronic myocarditis, one patient with aortic stenosis and reduced LV function after Ross procedure with ischaemic cardiomyopathy due to obstruction of the left coronary ostium and one patient with anomalous left coronary artery from the pulmonary artery with reduced LV function).
Table 2.
Clinical outcomes
| Total (N = 37) | N (%) |
|---|---|
| Survived to latest FU | 36 (97.3%) |
| Death during FU | 1 (2.7%) |
| Heart transplantation during FU | 4 (10.8%) |
| VAD implantation during FU | 5 (13.5%) |
| VAD explantation during FU (bridge to recovery) | 6 (16.2%) |
| Discharged from hospital at latest FU | 32 (86.5%) |
| Hospitalized at latest FU | 1 (2.7%) |
FU, follow‐up; VAD, ventricular assist device.
Figure 3.
Sankey diagram of clinical outcomes of the study cohort with incidence of VAD support at baseline and during the observation period. VAD, ventricular assist device.
We further evaluated LVEF and GLS as echocardiographic parameters of systolic heart function in patients with biventricular anatomy, NT‐proBNP and eGFR as indicators for HF and end‐organ dysfunction in all patients after 3–6 months and at the latest follow‐up in comparison with baseline examination. Results are summarized in Table 3 and Figure 4 .
Table 3.
Clinical parameters in follow‐up examinations
| Median (Q1, Q3) | ||||
|---|---|---|---|---|
| Baseline (B) | FU 3–6 month (3‐6) | Latest FU (L) | P‐value | |
| LVEF (%) |
N = 27 40.0 (25.0, 52.0) |
N = 19 51.0 (31.0, 59.0) |
N = 17 57.0 (39.5, 61.0) |
0.016 |
| GLS (%) |
N = 26 −9.2 (−14.0, −7.1) |
N = 17 −11.4 (−17.8, −8.2) |
N = 15 −14.9 (−18.7, −12.3) |
0.023 |
| NT‐proBNP | N = 37 | N = 20 | N = 17 | |
| (ng/mL) | 1,623 (616, 5,033) | 590 (263, 591) | 562 (262, 949) | 0.191 |
| Age‐adjusted zlog‐NT‐proBNP | 3.97 (2.91, 5.15) | 2.97 (1.53, 4.62) | 3.01 (1.52, 3.63) | 0.053 |
| eGFR (mL/kg/1.73 m2) |
N = 32 85 (68, 101) |
N = 18 80 (60, 100) |
N = 16 81 (64, 102) |
0.214 |
| NYHA/Ross | N = 32 | N = 24 | N = 23 | 0.004 |
| Class I | 10 (31.3%) | 16 (66.7%) | 18 (78.3%) | |
| Class II | 6 (18.8%) | 3 (12.5%) | 1 (4.3%) | |
| Class III | 6 (18.8%) | 4 (16.7%) | 3 (13.0%) | |
| Class IV | 10 (31.3%) | 1 (4.2%) | 1 (4.3%) | |
eGFR, estimated glomerular filtration rate; FU, follow‐up; GLS, global longitudinal strain; LVEF, left ventricular ejection fraction; NTproBNP, N‐terminal prohormone of B‐type natriuretic peptide; NYHA, New York Heart Association.
Bold p‐values show statistical significance.
Figure 4.
Left ventricular ejection fraction (LVEF, %), global longitudinal strain (GLS, %), age‐adjusted zlog NT‐proBNP levels and estimated glomerular filtration rate (eGFR, mL/kg/1.73 m2) at baseline, 3–6 months and latest follow‐up. *P < 0.05, **P < 0.01. NT‐proBNP, N‐terminal prohormone of B‐type natriuretic peptide.
Echocardiographic evaluation was only analysed in patients with biventricular anatomy, which were neither on VAD support (except if pump stop examination was available) nor transplanted at the time of evaluation. Six patients with SVHD, one patient on LVAD support with no eligible pump stop echocardiography and one transplanted patient with an abnormal heart axis were excluded at all‐time points. Baseline echocardiographic evaluation was therefore available for 27 patients. At 3–6 months follow‐up, echocardiographic evaluation was available for 19 patients. Three patients were excluded, as they were on VAD support with no eligible pump stop echocardiography, and three patients had been transplanted. For three patients, no follow‐up examination was available at 3–6 months. For the latest follow‐up (median 273 days, Q1, Q3: 182, 357) echocardiographic analysis has been conducted in 17 patients. Five patients had undergone heart transplantation, one was on biventricular VAD for the remaining patients, and no latest follow‐up examination was available.
We observed a significant increase of LVEF from 40.0% (Q1, Q3: 25.0, 52.0) at baseline to 51.0% (Q1, Q3: 31.0, 59.0, P = 0.012) at 3–6 months and further to 57.0% (Q1, Q3: 39.5, 61.0, P = 0.016) at the latest follow‐up. GLS increased from −9.1 (Q1, Q3: −14.0, −7.1) at baseline to −11.4 (Q1, Q3: −17.8, −8.2) at 3–6 months follow‐up and significantly increased further to −14.9 (Q1, Q3: −18.7, −12.3, P = 0.023) at the latest follow‐up. Data on B‐type natriuretic peptide (NT‐proBNP) were available for 37 patients at baseline, 20 patients at 3–6 months follow‐up and 17 patients at the latest follow‐up. NT‐proBNP decreased from 1,623 (Q1, Q3: 616, 5033) at baseline to 590 (Q1, Q3: 263, 591) at 3–6 months follow‐up and was 562 (Q1, Q3: 262–949) the latest follow‐up; however, differences are not statistically significant. Age‐adjusted zlog‐NT‐proBNP levels decreased from 3.97 (Q1, Q3: 2.91, 5.15) to 2.97 (Q1, Q3: 1.53, 4.62) to 3.01 (Q1, Q3: 1.53, 3.63, P = 0.053). We did not observe any significant change in eGFR over the observation period in our patient cohort. The distribution of NYHA/Ross functional class in patients that neither underwent heart transplantation nor received VAD implantation during follow‐up was compared at all‐time points. At baseline, 31.3% of the patients had no limitation of physical activity or heart failure symptoms (NYHA/Ross class I), 18.8% experienced heart failure symptoms during moderate exercise (NYHA/Ross class II) and 49.2% had severe limitation of physical activity with heart failure symptoms that interfere with normal daily activity, or they were unable to carry out any physical activity (NYHA/Ross class III or IV, Figure 5 ). After 3–6 months follow‐up, the percentage of patients with NYHA/Ross class I increased to 66.7%, 12.5% had mild exercise limitation (NYHA/Ross class II) and 20.9% remained with severe limitation of exercise capacity and heart failure symptoms (NYHA/Ross class III or IV). At the latest follow‐up, 78.3% of the patients were NYHA/Ross class I, one patient was in NYHA/Ross class II, and the percentage of patients in NYHA/Ross III or IV was 17.3% reaching a statistically significant difference when compared to baseline (P = 0.004).
Figure 5.
Functional NYHA/Ross class at baseline, 3–6 months and latest follow‐up. Patients that were on VAD or transplanted and those of which no follow‐up examination was available were excluded from the analysis. FU, follow‐up; NYHA, New York Heart Association; VAD, ventricular assist device.
Discussion
SGLT2 inhibitors have been successfully used in adult patients with conventional heart failure types reducing worsening of HF and the risk for cardiovascular‐related death. However, evidence for the use of SGLT2 inhibitors in paediatric and congenital heart failure patients is lacking. We therefore evaluated 37 paediatric patients that were treated with dapagliflozin for HF in addition to optimized medical therapy exploring therapy safety and tolerability, clinical outcomes and adverse events. The main finding of the study are as follows: (1) Despite the limited evidence for paediatric patients, SGLT2 inhibitors have been initiated with increasing frequency from 2022 onwards. (2) In our paediatric patient cohort, the use of dapagliflozin was safe and generally well‐tolerated. (3) Dapagliflozin in addition to optimized heart failure therapy was associated with improved NYHA/Ross functional class and improved systolic heart function (increase in LVEF and GLS) in paediatric HF patients with biventricular anatomy.
These findings are consistent with the limited number of studies on paediatric heart failure patients treated with SGLT2 inhibitors. Notably, our patient cohort, with a median age of 9.0 years (Q1, Q3: 2.4–12.8, range 0.2–17.1) was significantly younger than those reported in previous studies. For example, Newland et al. described a cohort with a median age of 12.2 (Q1, Q3: 6.2, 17.5) while another study on 14 patients with failing Fontan circulation, which included some paediatric cases, reported a median age of 14.5 years (range 2.0–26.4 years). 12 , 17
We did not observe any novel severe side effects and treatment had not to be discontinued due to adverse effects in any patient. This supports the very limited data that are available on paediatric heart failure patients, where SGLT2 inhibitors were generally well‐tolerated and is consistent with the observations made in adult HF patients. 12 , 17 , 18 By inducing glucosuria, urine tract infections have been reported frequently as adverse effects in adult and paediatric populations. 6 , 12 However, we did not observe any episodes of urine tract infection, which required antibiotic treatment.
Clinical trials in adult HF patients recognized a reduction in hospitalization for HF and a decrease in cardiovascular‐associated mortality. 3 , 4 , 8 Our study was a retrospective analysis of a rather small heterogenous paediatric patient cohort without a control group. As the incidence of rehospitalization and mortality was rare, an estimation of the effect of dapagliflozin on hospitalization rate and mortality was not possible. We analysed various clinical, echocardiographic and laboratory parameters in order to assess the clinical course of the paediatric patients treated with dapagliflozin. During the follow‐up period, all clinical parameters improved when compared to baseline. Exercise capacity and HF symptoms, which were only analysed in patients without VAD‐therapy or HT, significantly improved over the follow‐up period. SGLT2 inhibitors are postulated to improve cardiac function by decreasing pressure overload‐induced myocardial fibrosis leading to favourable cardiac remodelling. 2 Echocardiographic systolic function estimated by LVEF and GLS significantly improved from baseline to follow‐up examinations under therapy with dapagliflozin in addition to optimized HF therapy. Levels of NT‐proBNP decreased from baseline to follow‐up; however, that decrease was not statistically significant. Kidney function assessed by eGFR did not significantly improve over the observation period in our patient cohort, which was previously reported in adult and paediatric patients. 5 , 12 Notably, overall survival was 97.1% in this rather compromised paediatric HF cohort. Nevertheless, in the absence of a control cohort, we cannot conclusively assess the extent to which dapagliflozin influenced the clinical improvements of the patients and how the course of the disease would have progressed without SGLT2i therapy.
Conclusions
Dapagliflozin in addition to optimized therapy was safe and well tolerated in paediatric heart failure patients, and therapy was associated with improvements in functional class, left ventricular contractility and heart failure symptoms. No severe adverse events or therapy discontinuation for adverse effects were observed in our patients.
Limitations and future directions
The study is limited by the small sample size, the retrospective nature, the single‐centre approach and by the lack of a control group in order to estimate the effect of SGLT2i. Additionally, we had a very heterogeneous patient cohort with various diagnoses leading to heart failure. This limits the transfer of our results for routine clinical implementation. Further research, ideally multicentred prospective randomized controlled trials, are needed to conclusively evaluate the potential benefit of SGLT2i for paediatric heart failure patients.
Conflict of interest
There is no conflict of interest for any of the authors regarding this report.
Funding
No funding was received for conducting this study.
Acknowledgements
Lisa‐Maria Rosenthal is participant in the BIH Charité Digital Clinician Scientist Program funded by the Charité Universtiätsmedizin Berlin and Berlin Institute of Health at Charité (BIH).
Rosenthal, L.‐M. , Miera, O. , Krauss, A. , Danne, F. , Berger, F. , and Kramer, P. (2025) Initial clinical experience with dapagliflozin in addition to optimized medical therapy in paediatric heart failure patients. ESC Heart Failure, 12: 3494–3501. 10.1002/ehf2.15386.
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