A promise unfulfilled: the use of mineralocorticoid receptor antagonists in patients with heart failure and a reduced left ventricular ejection fraction

Abstract

This article refers to 'Temporal trends in initiation of mineralocorticoid receptor antagonists and risk of subsequent withdrawal in patients with heart failure: a nationwide study in Denmark from 2003-2017' by D. Zahir et al., published in this issue on pages 539-547.The steroidal mineralocorticoid receptor antagonists (MRAs) reduce mortality and hospitalizations for heart failure (HHF) in patients with heart failure and a reduced ejection fraction (HFrEF). Their incorporation into US and European guidelines as a class I indication for HFrEF held the promise for a substantial reduction in cardiovascular mortality, HHFs, and consequentially health care costs. It is therefore discouraging to observe that despite a class I indication in guidelines, over several years their use remains suboptimal in comparison to the other major guideline-recommended therapies for HFrEF.In this issue of the Journal, Zahir et al. 1 report upon the temporal trends in initiation and subsequent withdrawal of an MRA from a nationwide study of 51 512 patients with HFrEF in Denmark from 2003 to 2017. They found that only 40% of patients initiated an MRA within 6 months of their heart failure (HF) diagnosis. Furthermore, the use of an MRA did not increase significantly over the past decade. In those in whom an MRA was initiated, 49% of patients discontinued them and only 40% of these patients restarted them. The suboptimal use of MRAs in patients with HFrEF in Denmark 1 is unfortunately not unique. The US Get With the Guidelines Heart Failure Registry (GWTG-HF) 2 also found that the use of MRAs in patients with HFrEF was suboptimal, even in patients with normal renal function in whom the risk of inducing hyperkalaemia (HK) is minimal. In view of the widespread underutilization of MRAs and their poor persistence in patients with HFrEF 1,2 despite evidence of their benefit and repeated recommendations in guidelines, it is highly unlikely that further reemphasis and dissemination of guidelines will remedy the situation. Consequently, we proposeThe opinions expressed in this article are not necessarily those of the Editors of the European Journal of Heart Failure or of the European Society of Cardiology.

Underutilization of Mineralocorticoid Antagonists in Patients With Heart Failure With Reduced Ejection Fraction

“…6 Indeed, MRAs may be more underutilized than any other evidence-based therapy for HFrEF, prompting a recent trial specifically aimed at overcoming this problem. [7][8][9] Scrutiny of prescribing patterns suggests that MRAs are still reserved for patients with more severe functional limitation (NYHA functional classes III and IV) even though the EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure trial; NCT00232180) trial showed that eplerenone reduced the risks of both death and heart failure (HF) hospitalization in patients with mild symptoms, ie, in NYHA functional class II. 1 Physicians may be reluctant to add another treatment in patients with long-standing HF who appear to be stable on their current therapy and are mistakenly thought to be at low risk.…”

La importancia de los registros para nuestros pacientes

“…(5) No obstante, el hecho de que solo entre un tercio y la mitad de los pacientes con ICFEP reciban este tratamiento refleja la incertidumbre que aún persiste sobre su valor, una pregunta que se espera sea respondida por los ensayos en curso con antagonistas de los receptores de mineralocorticoides. (6) Los últimos hallazgos cruciales del presente registro son los resultados clínicos informados entre los pacientes inscritos, con una tasa anualizada del criterio de valoración compuesto de muerte por causas cardiovasculares u hospitalización por empeoramiento de la insuficiencia cardíaca del 12,8%, hospitalización por empeoramiento de la insuficiencia cardíaca del 9,8%, muerte por causas cardiovasculares del 6,6%, y muerte por cualquier causa del 8,4%. Si bien estas tasas son tan "buenas" como las observadas en ensayos recientes, lo que refleja la excelente terapia mencionada anteriormente, resaltan la necesidad de continuar desarrollando nuevos tratamientos y reducir aún más las tasas de eventos en la insuficiencia cardíaca.…”