Aldosterone, Mortality, and Acute Ischaemic Events in Coronary Artery Disease Patients Outside the Setting of Acute Myocardial Infarction or Heart Failure

Study Questions:

What is the relationship between the level of aldosterone and the risk of death and acute ischemic events in coronary artery disease (CAD) patients with a preserved left ventricular (LV) function and no acute myocardial infarction (MI)?

Methods:

In 799 consecutive CAD patients referred for elective coronary angioplasty, measurements were obtained before the procedure for: aldosterone (median 25 pg/ml), B-type natriuretic peptide (BNP) (median 35 pg/ml), high-sensitivity C-reactive protein (CRP) (median 4.17 mg/L), and LV ejection fraction (mean 58%). Patients with acute MI or acute coronary syndrome (ACS) who required urgent revascularization were not included in the study. The incremental prognosis value of aldosterone on top of variables included in the model was assessed using the integrated discrimination improvement (IDI) and the net reclassification improvement (NRI) models, with a category-free option.

Results:

The primary endpoint, cardiovascular death, occurred in 41 patients during a median follow-up period of 14.9 months. Secondary endpoints—total mortality, acute ischemic events (acute MI or ischemic stroke), and the composite of death and acute ischemic events—were observed in 52, 54, and 94 patients, respectively. Plasma aldosterone was found to be related to body mass index, hypertension, and New York Heart Association class, and inversely related to age, creatinine clearance, and use of beta-blockers. Multivariate Cox model analysis demonstrated that aldosterone was independently associated with cardiovascular mortality (p = 0.001), total mortality (p = 0.001), acute ischemic events (p = 0.01), and the composite of death and acute ischemic events (p = 0.004). Reclassification analysis, using IDI and NRI, demonstrated incremental predictive value of aldosterone (p < 0.0001).

Conclusions:

The authors concluded that in patients with CAD but without heart failure or acute MI, the level of aldosterone is strongly and independently associated with mortality and the occurrence of acute ischemic events.

Perspective:

This study suggests that plasma aldosterone is independently associated with long-term mortality in patients with CAD, and that aldosterone is associated with the risk of an acute ischemic event. In addition, aldosterone can provide complementary and incremental prognostic information to the most recently validated clinical and biological risk factors, including BNP and CRP, and that variations of aldosterone levels among patients with relatively low plasma concentrations of aldosterone can be predictive of clinical outcome. These findings support the need for a randomized controlled trial to assess the hypothesis that an aldosterone-receptor blockade may improve the prognosis of patients with CAD, with or without LV dysfunction.

Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Hypertension

Keywords: Coronary Artery Disease, Myocardial Infarction, Follow-Up Studies, Body Mass Index, Biological Markers, Heart Failure, New York, Ventricular Dysfunction, Left, Hypertension


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