SGLT-2 Inhibitor and Myocardial Perfusion, Function and Metabolism in T2 DM Patients at High Cardiovascular Risk

Inclusion Criteria: * A diagnosis of type 2 diabetes mellitus at least 3 months prior to baseline visit * For patients on background therapy: stable dose of anti-diabetics within 30 days prior to baseline * HbA1c of ≥6.5% and ≤10% at screening for patients on background therapy or HbA1c of ≥6.5 % and ≤ 9.0% at screening for drug-naïve patients. * BMI ≤ 45 kg/m2 at screening * Age ≥18 years * Negative pregnancy test (fertile women). Fertile women must use safe contraceptives (spiral, hormonal contraceptives) for the duration of the study * Able to understand the written patient information and to give informed consent * Patients must have high cardiovascular risk, defined as at least one of the following: * Albuminuria ( albumin/creatinine ratio ≥ 30 mg/g or plasma NT-proBNP ≥ 70 pg/ml) * Confirmed history of myocardial infarction (\>2 months prior to baseline) * Heart failure according to the Framingham Heart Failure Criteria * Or patient discharged from hospital with a documented diagnosis of unstable angina within 12 months prior to baseline * Evidence of coronary artery disease by CAG in 1 or more major coronary arteries OR at least one of the following: a positive noninvasive stress test, or A positive stress echocardiography showing regional systolic wall motion abnormalities, or A positive scintigraphic test showing stress-induced ischemia, * History of ischemic or haemorrhagic stroke (\>2 months prior to informed consent) * Presence of peripheral artery disease (symptomatic or not ) documented by either: previous limb angioplasty, stenting or bypass surgery; or previous limb or foot amputation due to circulatory insufficiency; or angiographic evidence of significant (\> 50%) peripheral artery stenosis in at least one limb; or evidence from a non-invasive measurement of significant (\>50% or as reported as hemodynamically significant) peripheral artery stenosis in at least one limb; or ankle brachial index of \< 0.9 Exclusion Criteria: * Allergic to the study medication * Treatment with SGLT-2 inhibitor within 3 months prior to baseline * Impaired kidney function, eGFR ≤ 30 ml/min * Severe liver insufficiency (Child-Pugh class C) * ECG showing malign ventricular arrhythmia or prolonged QT-interval (\>500ms) * Untreated clinical significant heart valve disease * Planned cardiac surgery or angioplasty within 3 months. * Myocardial infarction (MI) ≤ 30 days prior to baseline * Percutaneous coronary intervention (PCI) ≤ 4 weeks prior to baseline * History of coronary artery bypass graft (CABG) ≤ 8 weeks prior to enrollment * Prior history of heart transplantation * Unstable angina, known severe left main coronary artery stenosis, severe heart failure, uncontrolled arrhythmias, symptomatic hypotension or severe hypertension (systolic blood pressure \< 90 or \> 180 mmHg, respectively), sick sinus syndrome or \> 1st degree atrioventricular block in the absence of a functioning pacemaker * Requirement of emergent cardiac medical intervention or catheterization * Treatment with theophylline, or theophylline containing medications * History of known or suspected bronchoconstrictive or bronchospastic lung disease (e.g., asthma) * Pregnancy or desire hereof or breastfeeding. Additional exclusion criteria for hemodynamics substudy * LVEF ≤ 40 % evaluated at baseline echocardiography * Inability to perform a VO2 max test * Hypertrophic cardiomyopathy * Left ventricular assist device