Mineralocorticoid receptor antagonist pre-treatment and early post-treatment to minimize reperfusion injury after ST-elevation myocardial infarction: The MINIMIZE STEMI trial

Abstract

Background Mineralocorticoid receptor antagonist (MRA) therapy has been shown to prevent adverse left ventricular (LV) remodeling in ST-segment elevation myocardial infarction (STEMI) patients with heart failure. Whether initiating MRA therapy prior to primary percutaneous coronary intervention (PPCI) accrues additional benefit of reducing myocardial infarct size and preventing adverse LV remodeling is not known. We aimed to investigate whether MRA therapy initiated prior to reperfusion reduces myocardial infarct (MI) size and prevents adverse LV remodeling in STEMI patients. Methods STEMI patients presenting within 12 hours and with a proximal coronary artery occlusion with Thrombolysis In Myocardial Infarction flow grade 0 were consented and randomized to either an intravenous bolus of potassium canrenoate, followed by oral spironolactone for 3 months or matching placebo. The primary endpoint was MI size by cardiovascular magnetic resonance at 3 months. Results Sixty-seven patients completed the study. There was no significant difference in the final MI size at 3 months between the 2 groups (placebo: 17 ± 11%, MRA: 16 ± 10%, P = .574). There was also no difference in acute MI size (26 ± 16% versus 23 ± 14%, P = .425) or myocardial salvage (26 ± 12% versus 24 ± 8%, P = .456). At follow-up, there was a trend towards an improvement in LVEF (placebo: 49 ± 8%, MRA: 54 ± 11%, P = .053), and the MRA group had significantly greater percentage decrease in LVEDV (mean difference: −12.2 (95% CI −20.3 to −4.4)%, P = .003) and LVESV (mean difference: −18.2 (95% CI −30.1 to −6.3)%, P = .003). Conclusion This pilot study showed no benefit of MRA therapy in reducing MI size in STEMI patients when initiated prior to reperfusion, but there was an improvement in LV remodeling at 3 months. Adequately powered studies are warranted to confirm these findings.

SCMR Position Paper (2020) on clinical indications for cardiovascular magnetic resonance

“…Incorporating CMR’s precise myocardial biomarkers has accelerated the evaluation of a number of complementary therapeutic approaches. For instance, Bulluck and colleagues [ 192 ] evaluated treatment with a mineralocorticoid receptor antagonist drug intravenously at the time of primary percutaneous coronary intervention (PCI) and continued orally for 10 weeks after PCI; CMR was performed in the first week and again after 3 months. While mineralocorticoid receptor antagonist therapy did not reduce infarct size, LV remodeling did improve.…”

Qiliqiangxin reduced cardiomyocytes apotosis and improved heart function in infarcted heart through Pink1/Parkin -mediated mitochondrial autophagy

“…At present, treatment strategies for preventing left ventricular remodeling after myocardial infarction are still limited. Therefore, it is very necessary to conduct in-depth research on the pathological mechanism of myocardial injury and ventricular remodeling after myocardial infarction, and to determine additional treatment targets and treatment schemes to prevent the adverse effects of left ventricular remodeling after myocardial infarction [6].…”

Antialdosterone in Acute Myocardial Infarction patients: a Meta-Analysis and Systematic Review

“…The current TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial, NCT00094302) [33], ALBATROSS [13], and MINIMIZE STEMI [14] trials have shown little cardiovascular bene t from MRA therapy, raising the question of whether MRA treatment is bene cial for cardiovascular diseases. This meta analysis suggests that MRA treatment reverses cardiac remodeling and improves diastolic and systolic function and clinical prognosis in post-AMI patients.…”

“…However, in 2016, the ALBATROSS trial [13] (Aldosterone Lethal effects Blockade in Acute myocardial infarction Treated with or without Reperfusion to improve Outcome and Survival at Six months follow-up, NCT01176968) failed to show cardiovascular bene ts of MRA in patients admitted for AMI. Then, the current MINIMIZE STEMI trial [14] (Mineralocorticoid receptor antagonist pretreatment to MINIMISE reperfusion injury after ST-elevation myocardial infarction, NCT01882179) showed less adverse left ventricular remodeling in STEMI patients treated with MRA. The bene ts of MRA therapy for AMI patients remain controversial, and it is unclear whether AMI subtypes, treatment initiation time and duration, or left ventricular ejection fraction (LVEF) values affect MRA to improve clinical outcomes.…”