Mineralocorticoid Receptor Antagonists for Heart Failure With Reduced Ejection Fraction: Integrating Evidence into Clinical Practice


Mineralocorticoid receptor antagonists (MRAs) improve survival and reduce morbidity in patients with heart failure, reduced ejection fraction (HF-REF), and mild-to-severe symptoms, and in patients with left ventricular systolic dysfunction and heart failure after acute myocardial infarction. These clinical benefits are observed in addition to those of angiotensin converting enzyme inhibitors or angiotensin receptor blockers and beta-blockers. The morbidity and mortality benefits of MRAs may be mediated by several proposed actions, including antifibrotic mechanisms that slow heart failure progression, prevent or reverse cardiac remodelling, or reduce arrhythmogenesis. Both eplerenone and spironolactone have demonstrated survival benefits in individual clinical trials. Pharmacologic differences exist between the drugs, which may be relevant for therapeutic decision making in individual patients. Although serious hyperkalaemia events were reported in the major MRA clinical trials, these risks can be mitigated through appropriate patient selection, dose selection, patient education, monitoring, and follow-up. When used appropriately, MRAs significantly improve outcomes across the spectrum of patients with HF-REF.

Authors: Faiez Zannad, Wendy Gattis Stough, Patrick Rossignol, Johann Bauersachs, John J V McMurray, Karl Swedberg, Allan D Struthers, Adriaan A Voors, Luis M Ruilope, George L Bakris, Christopher M O’Connor, Mihai Gheorghiade, Robert J Mentz, Alain Cohen-Solal, Aldo P Maggioni, Farzin Beygui, Gerasimos S Filippatos, Ziad A Massy, Atul Pathak, Ileana L Piña, Hani N Sabbah, Domenic A Sica, Luigi Tavazzi, Bertram Pitt
Keywords: arrhythmias, endomyocardial fibrosis, heart failure, myocardial infarction, ventricular dysfunction, ventricular remodeling, mineralocorticoid receptor antagonists
DOI Number: 10.1093/eurheartj/ehs257      Publication Year: 2012

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