Eplerenone in patients with myocardial infarction and "mid-range" ejection fraction: An analysis from the EPHESUS trial

Secondary Prevention Therapies in Real-World Patients with Myocardial Infarction: Eligibility Based on Randomized Trials Supporting European and American Guidelines

OBJECTIVE

We aimed to evaluate the applicability of the eligibility criteria of randomized controlled trials (RCTs) cited in guideline recommendations in a real-world cohort of patients receiving secondary prevention after acute myocardial infarction from the EPICOR registries.

METHODS

Recommendations provided by American and European guidelines for acute myocardial infarction were classified into general (applying to all patients) and specific (applying to patients with left ventricular dysfunction or heart failure). Randomized controlled trials cited in these recommendations were selected, and their entry criteria were applied to our international cohort of 18,117 patients.

RESULTS

There were 91.5% patients eligible for beta blockers (84.6% for general, and 5.9% for specific recommendations), 97.7% eligible for renin-angiotensin system inhibitor (angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers [ACEI/ARB]) recommendations (69.9% for general, 27.9% for specific) and 4.1% eligible for mineralocorticoid receptor antagonists (only specific recommendations). The percentages of patients with eligibility criteria who were discharged with a prescription of the recommended therapies were 80%-85% for beta blockers, 70%-75% for ACEI/ARB, and 29% for mineralocorticoid receptor antagonists. There were large regional variations in the percentage of eligible patients and in those receiving the medications (eg, 95% in Northern Europe and 57% in Southeast Asia for beta blockers).

CONCLUSION

Most real-world acute myocardial infarction patients are eligible for secondary prevention therapy in both general and specific guideline recommendations, and the percentage of those on beta blockers and ACEI/ARB at hospital discharge is high. There are large regional variations in the proportion of patients receiving recommended therapies. Local targeted interventions are needed for quality improvement.

Effects of plasma aldosterone concentration and treatment with eplerenone on the survival of cats with chronic kidney disease

This study investigated the plasma aldosterone concentration (PAC) in cats with chronic kidney disease (CKD) and retrospectively evaluated the survival of cats with high PAC. Furthermore, this study prospectively examined eplerenone's effect on survival time in CKD cats with high PAC. The PAC was measured retrospectively in blood samples obtained from 156 client-owned cats that visited a veterinary hospital. The cats were designated into 2 groups: clinically healthy (n = 101) and those with CKD (n = 55). The PAC was measured by solid-phase radioimmunoassay; median (minimum-maximum) PAC in healthy cats was 97 pg/mL (range: 10 to 416 pg/mL) and the upper limit (95th percentile) was 243 pg/mL. In the CKD group, PAC [126 pg/mL (range: 10 to 981 pg/mL)] was higher (P < 0.01) than in the clinically healthy group. In cats with CKD, the survival time of those with high PAC (n = 16) (> 243 pg/mL) was shorter (P = 0.019) than that of those (n = 39) with normal PAC. Administering an aldosterone antagonist, eplerenone, at 2.5 to 5 mg/kg body weight prolonged survival (P = 0.005) in CKD cats with high PAC (n = 8). In conclusion, PAC could be a prognostic marker of CKD in cats and eplerenone may prolong survival in cats with CKD and a high PAC.

Advantages of long-term combination pharmacotherapy with a beta-blocker and eplerenone in patients with ST-segment elevation acute coronary syndrome

Aim. To conduct a comparative analysis of the effect of long-term pharmacotherapy (12 months) using a β-blocker (nebivolol) and its combination with eplerenone in patients after ST-segment elevation acute coronary syndrome (STE-ACS) with heart failure with mildly reduced ejection fraction (EF) (HFmrEF) on the structural and functional cardiac parameters.

Material and methods. We examined 130 patients with STE-ACS and HFmrEF after successful myocardial revascularization by percutaneous coronary intervention. The mean age of patients was 53,6 [46;57] years. Ten patients withdrew from the study due to personal reasons. Subsequently, patients were randomly divided into 2 treatment groups as follows: 60 patients received nebivolol; 60 patients received nebivolol and eplerenone. Patients were examined at two stages: 1st day of the disease before PCI and 12 months later. All patients underwent a clinical examination, echocardiography, followed by assessment of left ventricular (LV) EF, LV end-diastolic volume index (EDVI), LV endsystolic volume index (ESVI), LV myocardial index (LVMI), LV wall motion score index (WMSI), the ratio of peak early diastolic flow over peak late diastolic flow (E/A), the ratio of early diastolic transmitral flow velocity to the mitral annular velocity (E/e´).

Results. Twelve-month pharmacotherapy with nebivolol in patients after STE-ACS showed an increase in LVEF by 7,2% (p<0,05), a decrease in WMSI by 13,0% (p<0,05), an increase in the E/A ratio by 11,1% (р<0,05), decrease in the E/e’ ratio by 7,2% (р<0,05). LV EDVI increased by 4,6% (p>0,05). Twelve-month combined pharmacotherapy with nebivolol and eplerenone showed an increase in LVEF by 16,0% (p<0,01), a decrease in LV ESVI by 17,9% (p<0,05), and a decrease in WMSI by 26,7% (p<0,01), LVMI — by 23,8% (р<0,01). At the same time, LV EDVI decreased by 0,7% (p>0,05). The E/A ratio increased significantly by 22,2% (<0,01), E/e’ decreased by 29,6% (р<0,01). Comparative analysis also found that combination therapy had a more pronounced positive effect on LVEF (p<0,05), ESVI (p<0,05), WMSI (p<0,05), LVMI (p<0,01), as well as diastolic function in the form of a significant increase in E/A (p<0,05) and E/e’ (p<0,01), which recovered to normal values.

Conclusion. The advantages of long-term combination pharmacotherapy of nebivolol and eplerenone in HFmrEF patients after STE-ACS on both structural and functional cardiac parameters were established.

Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction Post-ST-Segment-Elevation Myocardial Infarction

Background Guidelines recommend mineralocorticoid receptor antagonist (MRA) use in patients with left ventricular ejection fraction ≤40% following a myocardial infarction plus heart failure or diabetes mellitus, based on mortality benefit in the EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial. The objective of this study was to evaluate the real-world utilization of MRAs for patients with ST-segment-elevation myocardial infarction (STEMI) with left ventricular dysfunction. Methods and Results The prospective, population-based, Vancouver Coastal Health Authority STEMI database was linked with local outpatient cardiology records from 2007 to 2018. EPHESUS criteria were used to define post-STEMI MRA eligibility (left ventricular ejection fraction ≤40% plus clinical heart failure or diabetes mellitus, and no dialysis-dependent renal dysfunction). The primary outcome was MRA prescription among eligible patients at discharge and the secondary outcome was MRA prescription within 3 months postdischarge. Of 2691 patients with STEMI, 317 (12%) were MRA eligible, and 70 (22%) eligible patients were prescribed an MRA at discharge. Among eligible patients with no MRA at discharge, 12/126 (9.5%) with documented postdischarge follow-up were prescribed an MRA within 3 months. In multivariable analysis, left ventricular ejection fraction (odds ratio [OR], 1.55 per 5% left ventricular ejection fraction decrease; 95% CI, 1.26-1.90) and calendar year (OR, 1.23 per year, 95% CI, 1.11-1.37) were associated with MRA prescription at discharge. Other prespecified variables were not associated with MRA prescription. Conclusions In this contemporary STEMI cohort, only 1 in 4 MRA-eligible patients were prescribed an MRA within 3 months following hospitalization despite high-quality evidence for use. Novel decision-support tools are required to optimize pharmacotherapy decisions during hospitalization and follow-up to target this gap in post-STEMI care.

Factors that predict ventricular arrhythmias in the late phase after acute myocardial infarction

Aims

Little is known regarding factors that predict the occurrence of lethal ventricular arrhythmias (VAs) occurring after acute myocardial infarction (AMI). This observational cohort study aimed to identify factors that predicted lethal VAs during the late phase after AMI in patients with reduced left ventricular ejection fraction (LVEF).

Methods and results

Data were collected from our AMI database regarding consecutive patients with an LVEF of ≤40% after AMI (January 2012 to July 2018). The ‘late phase’ was defined as ≥7 days after AMI onset, and the primary endpoint was defined as lethal VAs in the late phase. The study included 136 patients (82% men; mean age: 66 ± 13 years). The average LVEF at admission was 32.7 ± 8.2%. During a mean follow‐up period of 20.7 months, 14 patients (10%) experienced lethal VAs, including ventricular fibrillation (n = 8) and sustained ventricular tachycardia (n = 10). Univariate analyses revealed that lethal VAs were predicted by age and LVEF at admission. Receiver operating characteristic curve analysis indicated that the optimal cut‐off value was 23% for using the LVEF at admission to predict the primary endpoint (area under the curve: 0.77, P < 0.0001). Multivariable analysis also demonstrated that LVEF at admission was an independent predictor of the primary endpoint (risk ratio = 7.12, P = 0.001).

Conclusions

Lethal VAs in the late phase are common in patients with AMI, and reduced LVEF and cardiac function at admission play a significant role in the risk stratification for future lethal VAs in this population.

Assessment of the ESC quality indicators in patients with acute myocardial infarction: a systematic review

AIMS

To help improving quality of care in patients with acute myocardial infarction (AMI), the European Society of Cardiology (ESC) set 20 quality indicators (QIs). There is a need to compile and summarize QI availability, feasibility, and global compliance in real-world registries.

METHODS AND RESULTS

A systematic review of PubMed and Web of Science was conducted including all original articles reporting the use of the ESC QIs in AMI patients. Methods and reporting follow the guidelines of the PRISMA Statement and the protocol was registered in PROSPERO (CRD42020190541). Among the 220 screened citations, 9 studies met the inclusion criteria after full-text review. Among these 9 studies, there were 11 different cohorts. Patients were recruited from three different continents (31 countries). The number of QIs assessed ranged from 6 to 20, with 5 studies (56%) reporting data for at least 75% of the 20 QIs. There were room for improvement in terms of data availability (i.e. domain 6 measuring patient's satisfaction), feasibility (i.e. difficulties to find all data for composite QIs in domain 7), and attainment (i.e. high levels of compliance with the percentage of reperfused ST-segment elevation myocardial infarction patients, but low levels for a timely reperfusion).

CONCLUSIONS

Our systematic review has shown that it is possible to measure most QIs in existing registries, and that there is room for improvement in terms of data availability, feasibility, and levels of attainment to QIs. Our findings may influence the design of future registries to capture this information and help in QIs definition updates.

How Diabetes and Heart Failure Modulate Each Other and Condition Management

Heart failure (HF) and diabetes mellitus (DM) confer considerable burden on the health care system. Although these often occur together, DM can increase risk of HF, whereas HF can accelerate complications of DM. HF is a clinical syndrome resulting from systolic or diastolic impairment caused by ischemic, nonischemic (eg, DM), or other etiologies. HF exists along a spectrum from stage A (ie, persons at risk of DM) to stage D (ie, refractory HF from end-stage DM cardiomyopathy [DMCM]). HF is further categorized by reduced, midrange, and preserved ejection fraction (EF). In type 2 DM, the most prevalent form of DM, several pathophysiological mechanisms (eg, insulin resistance and hyperglycemia) can contribute to myocardial damage, leading to DMCM. Management of HF and DM and patient outcomes are guided by EF and drug efficacy. In this review, we focus on the interplay between HF and DM on disease pathophysiology, management, and patient outcomes. Specifically, we highlight the role of novel antihyperglycemic (eg, sodium glucose cotransporter 2 inhibitors) and HF therapies (eg, renin-angiotensin-aldosterone system inhibitors) on HF outcomes in patients with DM and HF.

Pre- and Post-Conditioning of the Heart: An Overview of Cardioprotective Signaling Pathways

Since the discovery of ischemic pre- and post-conditioning, more than 30 years ago, the knowledge about the mechanisms and signaling pathways involved in these processes has significantly increased. In clinical practice, on the other hand, such advancement has yet to be seen. This article provides an overview of ischemic pre-, post-, remote, and pharmacological conditioning related to the heart. In addition, we reviewed the cardioprotective signaling pathways and therapeutic agents involved in the above-mentioned processes, aiming to provide a comprehensive evaluation of the advancements in the field. The advancements made over the last decades cannot be ignored and with the exponential growth in techniques and applications. The future of pre- and post-conditioning is promising.

Prognostic impact of additional mineralocorticoid receptor antagonists in octogenarian heart failure patients

AIMS

Guideline-directed medical therapy (GDMT) including beta-blockers and renin-angiotensin system inhibitors is shown to reduce mortality risk in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, there is little evidence about the efficacy of additional administration of mineralocorticoid receptor antagonists (MRAs) with GDMT in patients ≥80 years presenting with HF. We aimed to investigate the prognostic impact of GDMT with MRA in relation to the age of patients with HF.

METHODS AND RESULTS

This observational study included patients admitted for HF with reduced LVEF who were discharged alive; among them, 224 patients were ≥80 years, and 661 patients were <80 years. Both populations were divided into three groups depending on whether they received GDMT with or without MRA or single/no GDMT drugs (GDMT+MRA+, GDMT+MRA-, or non-GDMT, respectively). The primary endpoint was all-cause mortality. In patients ≥80 years, all-cause mortality was the lowest in the GDMT+MRA+ group (log-rank trend, P = 0.034), and no significant differences were observed between the GDMT+MRA- and non-GDMT groups. Multivariate Cox regression analysis revealed that GDMT+MRA+ was superior to GDMT+MRA-, even after adjusting for parameters at discharge (hazard ratio: 0.32, 95% confidence interval: 0.11-0.99). In patients <80 years, GDMT reduced all-cause mortality; however, additional MRA was not associated with an improved outcome.

CONCLUSIONS

The results of this study suggest that additional MRA to GDMT at discharge is one of the therapeutic options for elderly HF patients with reduced LVEF. This finding is not well documented in previous clinical trials.

Reappraisal on pharmacological and mechanical treatments of heart failure

Heart failure (HF) is a highly frequent disorder with considerable morbidity, hospitalization, and mortality; thus, it invariably places pressure on clinical and public health systems in the modern world. There have been notable advances in the definition, diagnosis, and treatment of HF, and newly developed agents and devices have been widely adopted in clinical practice. Here, this review first summarizes the current emerging therapeutic agents, including pharmacotherapy, device-based therapy, and the treatment of some common comorbidities, to improve the prognosis of HF patients. Then, we discuss and point out the commonalities and areas for improvement in current clinical studies of HF. Finally, we highlight the gaps in HF research. We are looking forward to a bright future with reduced morbidity and mortality from HF.

Eplerenone in patients with myocardial infarction and "mid-range" ejection fraction: An analysis from the EPHESUS trial

Background

Trials using mineralocorticoid receptor antagonists (MRAs) in myocardial infraction (MI) without heart failure (HF) or systolic impairment have been underpowered to assess morbidity‐mortality benefit. In EPHESUS 6632 patients were included, of whom 11% had an ejection fraction (EF) of 40% and HF or diabetes. We aim to assess the potential benefit of MRAs in MI with EF of 40%.

Methods

Cox models with interaction term for EF. The primary outcome was a composite of cardiovascular death or hospitalization for cardiovascular reasons.

Hypothesis

Patients with an EF of 40% benefit similarly from MRA therapy to those with an EF <40%.

Results

In EPHESUS, 753 patients had an EF = 40% and 5864 an EF < 40%. Patients with an EF = 40% were younger (63 vs 64 years), had lower heart rate (73 vs 75 bpm), less atrial fibrillation (10% vs 14%), previous MI (21% vs 28%), HF hospitalization (5% vs 8%), and had more often reperfusion therapy and/or revascularization (55% vs 44%). The mean EF was 40.0 ± 0.3% in those with EF = 40% vs 32.2 ± 5.9% in those with EF < 40%. The primary outcome occurred in 13.3% (10 events per 100 py) of the patients with EF = 40% vs 22.9% (19 events per 100 py) in those with EF < 40%; adjusted HR for EF = 40% vs <40% = 0.65 (0.53‐0.81). Eplerenone reduced the event‐rate homogenously regardless of EF (interaction_p EF = 40% vs EF < 40% = 0.21). Similar findings were observed for cardiovascular and all‐cause death.

Conclusion

Eplerenone reduces hospitalizations and mortality in patients with MI and EF = 40% similarly to patients with EF < 40%. These findings suggest that MI patients with EF in the “mid‐range zone” may also benefit from MRA therapy which might help clinicians in their treatment decisions.