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Meta-Analysis of Mineralocorticoid Receptor Antagonists and AF
Quick Takes
- Mineralocorticoid receptor antagonists (MRAs) are effective in preventing CV events regardless of whether the patient has HF.
- Patients with AF and HF also benefit with decreased CV events with use of MRAs.
- MRAs may be moderately beneficial in preventing new or recurrent AF.
Study Questions:
Are the cardioprotective effects of mineralocorticoid receptor antagonists (MRAs) diminished by heart failure (HF) or atrial fibrillation (AF), and can MRAs prevent AF?
Methods:
The MEDLINE, Embase, and Cochrane Central Register of Control Trials databases were searched through March 24, 2023. The studies that were included compared MRAs to placebo in patients with cardiovascular (CV) disease or CV risk factors. Outcomes included CV death or HF hospitalization and AF and atrial flutter events (new or recurrent). A total of 20,741 participants were included with a mean age of 66 years; 32% were women.
Results:
The meta-analysis showed that MRAs reduced a composite of CV death or HF hospitalization (risk ratio, 0.81 and 0.84, respectively, for patients with and without HF). Within these groups, patients with and without AF had a similar reduction in CV death or HF hospitalization. Also, MRAs reduced AF events (risk ratio, 0.76) in patients with and without prior AF.
Conclusions:
MRAs are effective in preventing CV endpoints in patients with or without HF. The presence of AF did not reduce the efficacy in preventing the endpoints and, in fact, MRAs were effective in preventing recurrent or new AF.
Perspective:
There has been concern in the past that MRAs were less effective in preventing CV endpoints in HF patients with AF. In fact, some trials have shown that beta-blockers do not prevent HF hospitalization and mortality as well in patients with HF and AF. It is therefore interesting to investigate whether the beneficial effect of MRAs is attenuated in patients with AF. This extensive meta-analysis not only showed benefit of MRAs in patients with or without AF, but also showed that they may have an additional benefit of preventing new or recurrent AF in this population. This is a very reassuring set of findings and should further encourage us to use MRAs widely when indicated for appropriate patients regardless of their AF status. Additionally, we should use them a bit more enthusiastically in patients with a history of AF, as preventing recurrent AF is certainly a clinical benefit worth seeking.
Clinical Topics: Arrhythmias and Clinical EP, Heart Failure and Cardiomyopathies, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure
Keywords: Atrial Fibrillation, Heart Failure, Mineralocorticoid Receptor Antagonists
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