Aldosterone Antagonist Therapy in STEMI Patients Without HF

Study Questions:

What is the role of therapy with aldosterone antagonists in patients with ST-segment elevation myocardial infarction (STEMI) without congestive heart failure (CHF)?

Methods:

The investigators searched PubMed, Embase, CINAHL, and Cochrane Central databases for relevant references from the selected articles and published reviews from database inception through June 2017. Randomized clinical trials that evaluated treatment with aldosterone antagonists in patients with STEMI without clinical HF or left ventricular ejection fraction (LVEF) >40% were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct and report the meta-analysis, which used a random-effects model. Two investigators independently performed the database search and agreed on the final study selection. The outcomes analyzed were mortality, new CHF, recurrent MI, ventricular arrhythmia, and changes in LVEF, serum potassium level, and creatinine level at follow-up.

Results:

In all, 10 randomized clinical trials with a total of 4,147 unique patients were included in the meta-analysis. In patients who presented with STEMI without HF, treatment with aldosterone antagonists compared with control was associated with lower risk of mortality (2.4% vs. 3.9%; odds ratio [OR], 0.62; 95% confidence interval [CI], 0.42-0.91; p = 0.01) and similar risks of MI (1.6% vs. 1.5%; OR, 1.03; 95% CI, 0.57-1.86; p = 0.91), new CHF (4.3% vs. 5.4%; OR, 0.82; 95% CI, 0.56-1.20; p = 0.31), and ventricular arrhythmia (4.1% vs. 5.1%; OR, 0.76; 95% CI, 0.45-1.31; p = 0.33). Similarly, treatment with aldosterone antagonists compared with control was associated with a small yet significant increase in LVEF (mean difference, 1.58%; 95% CI, 0.18%-2.97%; p = 0.03), a small increase in serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; p = 0.02), and no change in serum creatinine level (standardized mean difference, 1.4; 95% CI, −0.43 to 3.24; p = 0.13).

Conclusions:

The authors concluded that treatment with aldosterone antagonists is associated with a mortality benefit in patients with STEMI with LVEF >40% or without HF.

Perspective:

This study reports a reduced risk of mortality associated with aldosterone antagonists compared with a control group in patients with STEMI without HF or reduced LVEF <40%. Patients who present with STEMI without HF appear to have survival benefit from aldosterone antagonists. Since STEMI and its adverse effects on morbidity and mortality remain major cardiovascular problems, clinicians may consider use of aldosterone antagonists in appropriate STEMI patients without HF. Adequately powered randomized studies are indicated to confirm the findings of this study.

Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure

Keywords: Acute Coronary Syndrome, Aldosterone, Arrhythmias, Cardiac, Creatinine, Diuretics, Heart Failure, Mineralocorticoid Receptor Antagonists, Myocardial Infarction, Potassium, Primary Prevention, Risk, Stroke Volume


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