Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction Post‐ST‐Segment–Elevation Myocardial Infarction

Abstract

Background Guidelines recommend mineralocorticoid receptor antagonist (MRA) use in patients with left ventricular ejection fraction ≤40% following a myocardial infarction plus heart failure or diabetes mellitus, based on mortality benefit in the EPHESUS (Eplerenone Post‐Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial. The objective of this study was to evaluate the real‐world utilization of MRAs for patients with ST‐segment–elevation myocardial infarction (STEMI) with left ventricular dysfunction. Methods and Results The prospective, population‐based, Vancouver Coastal Health Authority STEMI database was linked with local outpatient cardiology records from 2007 to 2018. EPHESUS criteria were used to define post‐STEMI MRA eligibility (left ventricular ejection fraction ≤40% plus clinical heart failure or diabetes mellitus, and no dialysis‐dependent renal dysfunction). The primary outcome was MRA prescription among eligible patients at discharge and the secondary outcome was MRA prescription within 3 months postdischarge. Of 2691 patients with STEMI, 317 (12%) were MRA eligible, and 70 (22%) eligible patients were prescribed an MRA at discharge. Among eligible patients with no MRA at discharge, 12/126 (9.5%) with documented postdischarge follow‐up were prescribed an MRA within 3 months. In multivariable analysis, left ventricular ejection fraction (odds ratio [OR], 1.55 per 5% left ventricular ejection fraction decrease; 95% CI, 1.26–1.90) and calendar year (OR, 1.23 per year, 95% CI, 1.11–1.37) were associated with MRA prescription at discharge. Other prespecified variables were not associated with MRA prescription. Conclusions In this contemporary STEMI cohort, only 1 in 4 MRA‐eligible patients were prescribed an MRA within 3 months following hospitalization despite high‐quality evidence for use. Novel decision‐support tools are required to optimize pharmacotherapy decisions during hospitalization and follow‐up to target this gap in post‐STEMI care.

Care and Outcomes of ST-Segment Elevation Myocardial Infarction Across Multiple COVID-19 Waves

“…In existence since 2007, this database (n = 4400 patients) provides continuous and ongoing collection of detailed pre-and in-hospital information on consecutive STEMI patients presenting to VCHA hospitals (12 hospitals serving 25% of the British Columbia (BC) population, urban and rural), for stakeholder reporting and quality improvement as previously described. [11][12][13] For the current study, STEMI patients were stratified into whether they presented during the COVID-19 pandemic (March 11 th , 2020 to January 31 st , 2021) vs. during a non-COVID-19 time period (March 11 th to January 31 st 2017, 2018, and 2019)(Figure 1). For secondary analyses, patients presenting during the COVID-19 pandemic were sub-classified into three distinct waves corresponding with three consecutive 109 day intervals into the following dates: wave 1 (March 11th to June 27th 2020), wave 2 (June 28th to October 14th 2020) and wave 3 (October 15th 2020 to January 31st 2021).…”

New Perspectives on Sex Steroid and Mineralocorticoid Receptor Signaling in Cardiac Ischemic Injury

“…MR antagonists have proven benefit for patients with all cause heart failure, with heart failure post-MI and in patients with moderate heart failure, and show potential for patients with heart failure with preserved ejection fraction (HFpEF) ( Pitt et al, 1999 ; Pitt et al, 2003 ; Markowitz et al, 2012 ; Miller and Howlett, 2015 ). Clinical studies ( Table 1 ) indicate that MR antagonists are underutilized and can provide specific benefit for patients with acute MI and high aldosterone levels ( Beygui et al, 2009 ; Rao et al, 2013 ; Wong et al, 2021 ). Serum biomarkers for collagen turnover within the RALES and EPHESUS trials indicated MR suppression limits structural remodeling of the extracellular matrix in all cause heart failure and post-MI.…”

Advantages of long-term combination pharmacotherapy with a beta-blocker and eplerenone in patients with ST-segment elevation acute coronary syndrome

“…В настоящее время установлено, что только 1 из 4 пациентов с ОКСпST с низкой ФВ ЛЖ назначается АМКР в течение 3 мес. после госпитализации, несмотря на имеющиеся доказательства высокого уровня ее эффективности для данной категории больных [17]. По результатам ретроспективного анализа исследования TOPCAT у пациентов с ФВ ЛЖ ≥45% установлено, что спиронолактон снижал частоту госпитализаций по поводу СН у пациентов с ФВ ЛЖ <55% [18], также было определено, что лечение с помощью АМКР может быть рассмотрено у пациентов с СНунФВ [17].…”