Mineralocorticoid Receptor Antagonists Associated With Reductions in Hospitalizations and Death Among Patients With Heart Failure

CLINICAL QUESTION

Is the treatment of heart failure with steroidal or nonsteroidal mineralocorticoid receptor antagonists associated with decreased heart failure hospitalizations and cardiovascular death?

BOTTOM LINE

The individual patient level meta-analysis confirms that steroidal mineralocorticoid receptor antagonists (spironolactone and eplerenone) reduce hospitalizations in patients across heart failure types and reduce cardiovascular death and all-cause mortality in patients with heart failure with reduced ejection fraction. The nonsteroidal mineralocorticoid finerenone (Kerendia) reduces mortality risk for patients with mildly reduced or preserved ejection fraction. There is a concomitant absolute increase of approximately 1.5 percentage points for severe hyperkalemia. (Level of Evidence = 1a)

SYNOPSIS

The authors present an individual patient level meta-analysis (13,846 participants) of four large studies of treatment with mineralocorticoid receptor antagonists vs placebo for the reduction of hospitalizations for heart failure and cardiovascular death in patients with heart failure with reduced ejection fraction (HFrEF; 40% or less), heart failure with mildly reduced ejection fraction (41%–49%), and heart failure with preserved ejection fraction (HFpEF; 50% or more). The study included two steroidal mineralocorticoid receptor antagonists (spironolactone and eplerenone) and one nonsteroidal mineralocorticoid receptor antagonist (finerenone). The latter was used in trials focused on patients with heart failure with mildly reduced ejection fraction and HFpEF because it did not demonstrate benefit in patients with HFrEF in the TOPCAT trial, one of the studies included in the meta-analysis. Baseline characteristics were balanced among groups. The primary outcome was time to first hospitalization for heart failure or cardiovascular death.