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Oraii A, Healey JS, Kowalik K, Pandey AK, Benz AP, Wong JA, Conen D, McIntyre WF. Mineralocorticoid receptor antagonists and atrial fibrillation: a meta-analysis of clinical trials. Eur Heart J 2024; 45:756-774. [PMID: 38195054 DOI: 10.1093/eurheartj/ehad811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND AIMS Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in a variety of settings. This study aimed to assess whether cardioprotective effects of MRAs are modified by heart failure (HF) and atrial fibrillation (AF) status and to study their impact on AF events. METHODS MEDLINE, Embase, and Cochrane Central databases were searched to 24 March 2023 for randomized controlled trials evaluating the efficacy of MRAs as compared with placebo or usual care in reducing cardiovascular outcomes and AF events in patients with or at risk for cardiovascular diseases. Random-effects models and interaction analyses were used to test for effect modification. RESULTS Meta-analysis of seven trials (20 741 participants, mean age: 65.6 years, 32% women) showed that the efficacy of MRAs, as compared with placebo, in reducing a composite of cardiovascular death or HF hospitalization remains consistent across patients with HF [risk ratio = 0.81; 95% confidence interval (CI): 0.67-0.98] and without HF (risk ratio = 0.84; 95% CI: 0.75-0.93; interaction P = .77). Among patients with HF, MRAs reduced cardiovascular death or HF hospitalization in patients with AF (hazard ratio = 0.95; 95% CI: 0.54-1.66) to a similar extent as in those without AF (hazard ratio = 0.82; 95% CI: 0.63-1.07; interaction P = .65). Pooled data from 20 trials (21 791 participants, mean age: 65.2 years, 31.3% women) showed that MRAs reduce AF events (risk ratio = 0.76; 95% CI: 0.67-0.87) in both patients with and without prior AF. CONCLUSIONS Mineralocorticoid receptor antagonists are similarly effective in preventing cardiovascular events in patients with and without HF and most likely retain their efficacy regardless of AF status. Mineralocorticoid receptor antagonists may also be moderately effective in preventing incident or recurrent AF events.
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Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - Krzysztof Kowalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Avinash K Pandey
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
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Gu J, Zhu H, Zhu D, Li M, Xiao M, Yan D, Shen S. VWF, CXCL8 and IL6 might be potential druggable genes for acute coronary syndrome (ACS). Comput Biol Chem 2019; 83:107125. [DOI: 10.1016/j.compbiolchem.2019.107125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 09/02/2019] [Accepted: 09/10/2019] [Indexed: 01/31/2023]
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Bulluck H, Fröhlich GM, Nicholas JM, Mohdnazri S, Gamma R, Davies J, Sirker A, Mathur A, Blackman D, Garg P, Moon JC, Greenwood JP, Hausenloy DJ. Mineralocorticoid receptor antagonist pre-treatment and early post-treatment to minimize reperfusion injury after ST-elevation myocardial infarction: The MINIMIZE STEMI trial. Am Heart J 2019; 211:60-67. [PMID: 30893577 PMCID: PMC6483973 DOI: 10.1016/j.ahj.2019.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 02/11/2019] [Indexed: 01/28/2023]
Abstract
Background Mineralocorticoid receptor antagonist (MRA) therapy has been shown to prevent adverse left ventricular (LV) remodeling in ST-segment elevation myocardial infarction (STEMI) patients with heart failure. Whether initiating MRA therapy prior to primary percutaneous coronary intervention (PPCI) accrues additional benefit of reducing myocardial infarct size and preventing adverse LV remodeling is not known. We aimed to investigate whether MRA therapy initiated prior to reperfusion reduces myocardial infarct (MI) size and prevents adverse LV remodeling in STEMI patients. Methods STEMI patients presenting within 12 hours and with a proximal coronary artery occlusion with Thrombolysis In Myocardial Infarction flow grade 0 were consented and randomized to either an intravenous bolus of potassium canrenoate, followed by oral spironolactone for 3 months or matching placebo. The primary endpoint was MI size by cardiovascular magnetic resonance at 3 months. Results Sixty-seven patients completed the study. There was no significant difference in the final MI size at 3 months between the 2 groups (placebo: 17 ± 11%, MRA: 16 ± 10%, P = .574). There was also no difference in acute MI size (26 ± 16% versus 23 ± 14%, P = .425) or myocardial salvage (26 ± 12% versus 24 ± 8%, P = .456). At follow-up, there was a trend towards an improvement in LVEF (placebo: 49 ± 8%, MRA: 54 ± 11%, P = .053), and the MRA group had significantly greater percentage decrease in LVEDV (mean difference: −12.2 (95% CI −20.3 to −4.4)%, P = .003) and LVESV (mean difference: −18.2 (95% CI −30.1 to −6.3)%, P = .003). Conclusion This pilot study showed no benefit of MRA therapy in reducing MI size in STEMI patients when initiated prior to reperfusion, but there was an improvement in LV remodeling at 3 months. Adequately powered studies are warranted to confirm these findings.
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Xu Y, Qiu Z, Yang R, Wu Y, Cheng X. Efficacy of mineralocorticoid receptor antagonists in postmyocardial infarction patients with or without left ventricular dysfunction: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e13690. [PMID: 30572494 PMCID: PMC6319977 DOI: 10.1097/md.0000000000013690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There is heated debate about the benefits of using mineralocorticoid receptor antagonists (MRAs) in addition to standard therapy in patients admitted for myocardial infarction (MI) with or without left ventricular dysfunction (LVD). METHODS Randomized controlled trials (RCTs) were scanned by a formal search of electronic databases (PubMed, EMBASE, Cochrane Library, Ovid, and clinical trials) from their inception to April 2018. A meta-analysis was conducted using Review Manager 5.3 to identify studies reporting the efficacy of MRAs use in post-MI patients with or without LVD. RESULTS Thirteen RCTs involving 11,365 individuals were eligible for this study. MRAs treatment reduced all-cause mortality by 16%, cardiovascular death by 16%, and death from heart failure (HF) by 22% in post-MI patients. MRAs use reduced all-cause mortality by 13% and cardiovascular death by 15% in post-MI patients with LVD, but there was no significant difference in all-cause mortality and cardiovascular death in post-MI patients without LVD (relative ratios [RR] 0.83, 95% confidence interval [CI] 0.26-2.69, P = .76, I = 0%; RR 1.01, 95% CI 0.33-3.09, P = .99, I = 0%). In 6 RCTs involving post-MI patients, MRAs treatment had a significant effect on improving left ventricular ejection fraction (LVEF) (mean difference 3.33, 95% CI 0.91-5.75, P = .007, I = 94%). Patients treated with MRAs did not show a decrease in recurrent MI or repeat revascularization compared with patients treated without MRAs (RR 0.95, 95% CI [0.80-1.12], P = .54, I = 0%; RR 1.09, 95% CI [0.79-1.50], P = .61, I = 0%). However, MRAs treatment significantly increased the incidence of hyperkalemia compared with patients treated without MRAs (RR 2.05, 95% CI [1.60, 2.61], P < .00001, I = 49%). CONCLUSION MRAs treatment reduced all-cause mortality, cardiovascular death, and death from HF in post-MI patients. MRAs treatment also demonstrated a significant improvement in LVEF. MRAs reduced cardiovascular death and all-cause mortality in patients with LVD. Eplerenone significantly reduced all-cause mortality and cardiovascular death in post-MI patients. However, MRAs failed to show any cardiovascular benefit in post-MI patients without LVD.
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Affiliation(s)
- Yan Xu
- Department of Cardiovascular, Institute of Cardiovascular Disease
| | - Zhiqiang Qiu
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Renqiang Yang
- Department of Cardiovascular, Institute of Cardiovascular Disease
| | - Yanqing Wu
- Department of Cardiovascular, Institute of Cardiovascular Disease
| | - Xiaoshu Cheng
- Department of Cardiovascular, Institute of Cardiovascular Disease
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Dahal K, Hendrani A, Sharma SP, Singireddy S, Mina G, Reddy P, Dominic P, Modi K. Aldosterone Antagonist Therapy and Mortality in Patients With ST-Segment Elevation Myocardial Infarction Without Heart Failure: A Systematic Review and Meta-analysis. JAMA Intern Med 2018; 178:913-920. [PMID: 29799995 PMCID: PMC6145720 DOI: 10.1001/jamainternmed.2018.0850] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Treatment with aldosterone antagonists is recommended and has been shown to have beneficial effects in patients with ST-segment elevation myocardial infarction (STEMI) and left ventricular ejection fraction (LVEF) less than 40%. However, the role of aldosterone antagonists in patients with ejection fraction greater than 40% or without congestive heart failure is not well known. OBJECTIVES To perform a systematic review and meta-analysis using standard techniques to determine the role of therapy with aldosterone antagonists in this patient population. DATA SOURCES PubMed, Embase, CINAHL, and Cochrane Central databases were searched and a manual search for relevant references from the selected articles and published reviews was performed from database inception through June 2017. STUDY SELECTION Randomized clinical trials that evaluated treatment with aldosterone antagonists in patients with STEMI without clinical heart failure or LVEF greater than 40% were included. DATA EXTRACTION AND SYNTHESIS Preferred Reporting Items for Systematic Reviews and Meta-analyses 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. A manual search was performed for relevant references from the selected articles and published reviews. MAIN OUTCOMES AND MEASURES The outcomes analyzed were mortality, new congestive heart failure, recurrent myocardial infarction, 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 4147 unique patients were included in the meta-analysis. In patients who presented with STEMI without heart failure, 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% CI, 0.42-0.91; P = .01) and similar risks of myocardial infarction (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; P = .91), new congestive heart failure (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; P = .31), and ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; P = .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 = .03), a small increase in serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; P = .02), and no change in serum creatinine level (standardized mean difference, 1.4; 95% CI, -0.43 to 3.24; P = .13). CONCLUSIONS AND RELEVANCE Treatment with aldosterone antagonists is associated with a mortality benefit in patients with STEMI with LVEF greater than 40% or without heart failure.
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Affiliation(s)
- Khagendra Dahal
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport
| | - Aditya Hendrani
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport
| | - Sharan P Sharma
- Department of Medicine, LRGHealthcare, University of New England, Laconia, New Hampshire
| | - Sampath Singireddy
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport
| | - George Mina
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport
| | - Pratap Reddy
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport
| | - Paari Dominic
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport
| | - Kalgi Modi
- Division of Cardiology, Department of Medicine, Louisiana State University Health Sciences Center, Shreveport
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Hinton J, Mahmoudi M, Myat A, Curzen N. The role of mineralocorticoid receptor antagonists in patients with acute myocardial infarction: Is the evidence reflective of modern clinical practice? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:452-456. [PMID: 29730238 DOI: 10.1016/j.carrev.2018.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/14/2018] [Accepted: 04/10/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, Department of Cardiology, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Michael Mahmoudi
- Coronary Research Group, Department of Cardiology, University Hospital Southampton, Southampton SO16 6YD, UK; Faculty of Medicine, University of Southampton, UK
| | - Aung Myat
- University of Brighton and Brighton and Sussex Medical School, UK
| | - Nick Curzen
- Coronary Research Group, Department of Cardiology, University Hospital Southampton, Southampton SO16 6YD, UK; Faculty of Medicine, University of Southampton, UK.
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Galectin-3 in acute coronary syndrome. Clin Biochem 2017; 50:797-803. [DOI: 10.1016/j.clinbiochem.2017.04.018] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/20/2017] [Accepted: 04/25/2017] [Indexed: 11/18/2022]
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Rajagopalan S, Alaiti MA, Broadwater K, Goud A, Gaztanaga J, Connelly K, Fares A, Shirazian S, Kreatsoulas C, Farkouh M, Dobre M, Fink JC, Weir MR. Design of the Magnetic Resonance Imaging Evaluation of Mineralocorticoid Receptor Antagonism in Diabetic Atherosclerosis (MAGMA) Trial. Clin Cardiol 2017; 40:633-640. [PMID: 28555959 DOI: 10.1002/clc.22718] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 12/13/2022] Open
Abstract
Mineralocorticoid receptor (MR) activation plays an essential role in promoting inflammation, fibrosis, and target organ damage. Currently, no studies are investigating MR antagonism in patients with type 2 diabetes mellitus (T2DM) with chronic kidney disease, at high risk for cardiovascular complications, who are otherwise not candidates for MR antagonism by virtue of heart failure. Further, there is limited information on candidate therapies that may demonstrate differential benefit from this therapy. We hypothesized that MR antagonism may provide additional protection from atherosclerosis progression in higher-risk patients who otherwise may not be candidates for such a therapeutic approach. In this double-blind, randomized, placebo-controlled trial, subjects with T2DM with chronic kidney disease (≥ stage 3) will be randomized in a 1:1 manner to placebo or spironolactone (12.5 mg with eventual escalation to 25 mg daily over a 4-week period). The co-primary efficacy endpoint will be percentage change in total atheroma volume in thoracic aorta and left ventricular mass at 52 weeks in patients treated with spironolactone vs placebo. Secondary outcomes include 24-hour mean systolic blood pressure, central aortic blood pressure, and insulin resistance (HOMA-IR) at 6 weeks. A novel measure in the study will be changes in candidate miRNAs that regulate expression of NR3C2 (MR gene) as well as measuring monocyte/macrophage polarization in response to therapy with spironolactone. We envision that our strategy of simultaneously probing the effects of a drug combined with analysis of mechanisms of action and predictive response will likely provide key information with which to design event-based trials.
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Affiliation(s)
- Sanjay Rajagopalan
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center, Ohio.,University of Maryland School of Medicine, Baltimore
| | - M Amer Alaiti
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center, Ohio
| | | | - Aditya Goud
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center, Ohio
| | - Juan Gaztanaga
- Division of Internal Medicine, Department of Cardiology, NYU Winthrop Hospital, Mineola, New York
| | - Kim Connelly
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Anas Fares
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals, Cleveland Medical Center, Ohio
| | - Shayan Shirazian
- Division of Nephrology and Hypertension, Diabetes and Obesity Research Center, NYU Winthrop Hospital, Mineola, New York
| | | | - Michael Farkouh
- Department of Cardiology, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Mirela Dobre
- Division of Nephrology, University Hospitals, Cleveland Medical Center, Ohio
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van den Berg TNAD, van Swieten HA, Vos JC, Verweij V, Wouterse AC, Deinum J, Morshuis WJ, Rongen GA, Riksen NP. Eplerenone does not limit ischemia-reperfusion injury in human myocardial tissue. Int J Cardiol 2016; 216:110-3. [PMID: 27149239 DOI: 10.1016/j.ijcard.2016.04.150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 04/16/2016] [Indexed: 12/11/2022]
Affiliation(s)
- T N A Daniëlle van den Berg
- Department of Pharmacology and Toxicology, Radboud university medical center, Nijmegen, The Netherlands; Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - H A van Swieten
- Department of Cardiothoracic Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - J C Vos
- Department of Pharmacology and Toxicology, Radboud university medical center, Nijmegen, The Netherlands
| | - V Verweij
- Department of Pharmacology and Toxicology, Radboud university medical center, Nijmegen, The Netherlands
| | - A C Wouterse
- Department of Pharmacology and Toxicology, Radboud university medical center, Nijmegen, The Netherlands
| | - J Deinum
- Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - W J Morshuis
- Department of Cardiothoracic Surgery, Radboud university medical center, Nijmegen, The Netherlands
| | - G A Rongen
- Department of Pharmacology and Toxicology, Radboud university medical center, Nijmegen, The Netherlands; Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
| | - N P Riksen
- Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands.
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