SGLT2i and aortic valve stenosis: impact on valve calcification

Abstract

Background: Aortic valve stenosis (AVS) is a cardiovascular disease characterized by a continuous process of fibrosis and calcification mainly led by the activation of valvular interstitial cells (VICs). Despite its high prevalence, there is still no effective pharmacological therapies to prevent or to treat this disease. Sodium-glucose co-transporter 2 inhibitors (SGLT2i), such as empagliflozin (EMPA), have shown cardiovascular benefits, but their direct effects on VICs remain unclear. This study aimed to investigate the effects of SGLT2i on VICs'-mediated calcification. Methods: Human VICs were isolated from aortic valves of six patients (three men and three women) undergoing surgical valve replacement for severe AVS. Cells were isolated, expanded and cultured under either baseline conditions (VIC-GM) or pro-osteogenic medium (OM), with increasing concentrations of EMPA. After 21 days, cell viability was assessed using a Resazurin Assay, and calcification was quantified by Alizarin Red S staining, followed by image analysis. Results: VICs maintained viability above 70% at all EMPA concentrations tested, up to 100 µM, indicating good drug tolerance. However, significant reductions in viability were detected from 10 µM onward in men. Male-derived VICs exhibited significantly higher baseline calcification compared to female-derived VICs (66.4% vs. 38.0%, p=0.0003), suggesting intrinsic sex-related differences in osteogenic potential. Under osteogenic stimulation, EMPA reduced calcification in male VICs at 10 µM (11.6%, p=0.0392). In contrast, female VICs showed no significant reduction in calcification. These findings suggest a sex-specific cellular response to EMPA. Conclusions: EMPA may attenuate VIC-mediated calcification in a sex-specific manner, reducing calcium deposition in male-derived VICs but not in those from females. These findings suggest that SGLT2i could represent a novel pharmacological strategy for men with AVS and reinforce the importance of considering sex differences in the development of novel therapies.