Clinical benefit of spironolactone in patients with acute decompensated heart failure and severe renal dysfunction: Data from the Korean Heart Failure Registry

Real-world evidence for steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease

Background

Mineralocorticoid receptor antagonists (MRAs) were shown to delay chronic kidney disease (CKD) progression in patients with hypertension and/or heart failure (HF) and proteinuria.

Objective

We conducted a systematic literature review on real-world evidence to identify the literature gaps related to the efficacy and safety outcomes of MRAs administered to CKD patients.

Results

A total of 751 records were identified of which, 23 studies (26 publications) were analyzed. Studies included heterogeneous populations, including the overall CKD, CKD and diabetes, CKD and HF, and CKD and a history of cardiovascular disease. Most of the studies were small and non-rigorous, resulting in a notable lack of evidence in these populations. In the overall CKD population, steroidal MRAs resulted in a significant or sustained eGFR reduction but no efficacy in delaying progression to end-stage kidney disease. No cardiovascular protection was found. Results for all-cause mortality and hospitalization for HF were inconsistent; however, the longest follow-up studies indicate similar or lower incidence for spironolactone non-users. Most results consistently reported a higher incidence of hyperkalemia among patients on steroidal MRAs in all CKD stages, and side effects led to high discontinuation rates in the real-world setting.

Conclusions

Despite the limited availability of evidence on the effectiveness and safety of steroidal MRAs in CKD patients and subgroups with diabetes, HF or history of cardiovascular disease, MRAs were shown to have a limited effect on renal and cardiovascular outcomes. Gaps in the evidence regarding the efficacy and safety of MRAs are particularly relevant in diabetic CKD patients; therefore, further research is warranted.

An overview of mineralocorticoid receptor antagonists as a treatment option for patients with heart failure: the current state-of-the-art and future outlook

INTRODUCTION

Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in patients with heart failure. These benefits of MRAs vary in different heart failure populations based on left ventricular ejection fraction and associated comorbidities.

AREAS COVERED

We define the pharmacologic properties of MRAs and the pathophysiological rationale for their utility in heart failure. We outline the current literature on the use of MRAs in different heart failure populations, including reduced and preserved ejection fraction (HFrEF/ HFpEF), and acute heart failure decompensation. Finally, we describe the limitations of currently available data and propose future directions of study.

EXPERT OPINION

While there is strong evidence supporting the use of MRAs in HFrEF, evidence in patients with HFpEF or acute heart failure is less definitive. Comorbidities such as obesity or atrial fibrillation could be clinical modifiers of the response to MRAs and potentially alter the risk/benefit ratio in these subpopulations. Emerging evidence for new non-steroidal MRAs reveal promising preliminary results that, if confirmed in large randomized clinical trials, could favor a change in clinical practice.

The Prescription Characteristics, Efficacy and Safety of Spironolactone in Real-World Patients With Acute Heart Failure Syndrome: A Prospective Nationwide Cohort Study

Background

Randomized clinical trials of spironolactone showed significant mortality reduction in patients with heart failure with reduced ejection fraction. However, its role in acute heart failure syndrome (AHFS) is largely unknown.

Aim

To investigate the prescription characteristics, efficacy and safety of spironolactone in real-world patients with AHFS.

Methods

5,136 AHFS patients who survived to hospital discharge using a nationwide prospective registry in Korea were analyzed. The primary efficacy outcome was 3-year all-cause mortality.

Results

Spironolactone was prescribed in 2,402 (46.8%) at discharge: <25 mg in 890 patients (37.1%), ≥25 mg, and <50 mg in 1,154 patients (48.0%), and ≥50 mg in 358 patients (14.9%). Patients treated with spironolactone had a lower proportion of chronic renal failure and renal replacement therapy during hospitalization and had lower serum creatinine level than those who did not. In overall patients, 3-year mortality was not different in both groups (35.9 vs. 34.5%, P = 0.279). The incidence of renal injury and hyperkalemia was 2.2% and 4.3%, respectively, at the first follow-up visit. The treatment effect of spironolactone on mortality was different across subpopulations according to LVEF. The use of spironolactone was associated with a significant reduction in 3-year morality in patients with LVEF ≤ 26% (33.8 vs. 44.3%, P < 0.001; adjusted HR 0.79, 95% CI 0.64–0.97, P = 0.023), but not in patients with LVEF > 26%.

Conclusions

Although spironolactone was frequently used at lower doses in real-world practice, use of spironolactone significantly reduced 3-year mortality in patients with severely reduced LVEF with acceptable safety profile. However, our findings remain prone to various biases and further prospective randomized controlled studies are needed to confirm these findings.

Treatment of advanced heart failure

Background: The development of medical and device treatment of heart failure (HF) has improved the survival and quality of life in HF patients. However, not all HF patients respond well to these up-to-date HF treatments. We have termed these non-responders as advanced HF patients. The definition, diagnosis, and treatment of advanced HF are discussed in this review article.Current Concepts: After current guideline-directed treatments, advanced HF patients can experience aggravation and decompensation, usually resulting in hospitalization for the symptoms and volume control. Recurrent decompensation or hospitalization can cause a vicious cycle between the heart and other vital organs, such as the kidney and liver. Current and up-to-date guidelines recommend treatments, including heart transplant, left ventricular assist device (LVAD), and hospice care, for advanced HF. Given the limitation of heart transplant donors, LVAD can be used as a bridge to transplant, in addition to destination therapy. Updated LVAD system can reduce pump-related thrombosis, stroke, and bleeding.Discussion and Conclusion: Current guidelines suggest early recognition of advanced HF and referral to advanced HF specialists. Despite advances in the treatments of advanced HF, unmet needs for further improving clinical outcomes and quality of life exist.

Efficacy and safety of spironolactone for the treatment of patients with acute heart failure: A protocol for systematic review

BACKGROUND

This study will investigate the efficacy and safety of spironolactone for the treatment of acute heart failure (AHF).

METHODS

The following electronic databases will be retrieved in PUBMED, EMBASE, Cochrane Library, Web of Science, CINAHL, CBM, CNKI, and VIP database from inception through present. Two researchers will independently screen and assess the obtained literatures and extract outcome data. All study methodological quality will be assessed using Cochrane risk of bias tool, and all statistical analysis will be performed by RevMan 5.3 software. Additionally, we will undertake a narrative synthesis if it is possible.

RESULTS

This study will sum-marize most recent evidence to investigate the efficacy and safety of spironolactone for the treatment of AHF.

CONCLUSION

This study will seek to assess the efficacy and safety of spironolactone for treating AHF.

SYSTEMATIC REVIEW REGISTRATION

INPLASY202070053.

Mineralocorticoid receptor antagonists in patients with chronic kidney disease

Mineralocorticoid receptor antagonists (MRA) can reduce cardiovascular morbidity and mortality in patients with heart failure and ischemic heart disease. In addition, these agents have been used in patients with diabetic nephropathy to control proteinuria and slow down chronic kidney disease (CKD) progression. Current guidelines recommend against the use of MRAs in patients with advanced CKD. However, there is growing interest on their use in this population that has unmet needs (high cardiovascular morbidity and mortality) and unique challenges (risk of acute kidney injury or hyperkalemia). This narrative review discusses the emerging role of MRAs for the management of cardiovascular disease and/or the prevention of CKD progression, highlighting results from randomized controlled trials and presenting real-world data from available registries. Results from recent trials in patients on maintenance dialysis are also discussed.

Efficacy and Safety of Mineralocorticoid Receptor Antagonists in Patients With Heart Failure and Chronic Kidney Disease

Mineralocorticoid receptor antagonists (MRA) improve clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF) and reduce risk of heart failure (HF) hospitalization in patients with heart failure with preserved ejection fraction (HFpEF). However, the benefit and risks of MRA use are not clear in HF patients and chronic kidney disease (CKD) with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m². We conducted a systematic review evaluating the efficacy and safety of MRA in patients with HF and CKD. PubMed, Embase, and Cochrane Central databases were searched for relevant studies on patients with HF and reduced renal function (defined as eGFR <60 mL/min/1.73 m²). Seven studies with 5,522 patients were included. We found 3 studies in patients with HFrEF, 1 study with HFpEF, and 2 in acute HF and 1 with mixed patient population of HF. Post hoc analyses from randomized controlled trials demonstrated reduction of risk in the primary end point (adverse cardiovascular outcomes and/or all-cause mortality and/or HF hospitalization) with MRA use in the CKD subgroup (eGFR 30 to 60 mL/min/1.73 m²) despite a greater risk of hyperkalemia and higher rates of drug discontinuation. In 3 observational studies, propensity score matching was performed to compare patients treated with and without MRA and did not identify benefits, but conclusions from these studies were limited due to residual confounding and concern for bias. In conclusion, benefits of MRA use in HF appear to be consistent in patients with reduced renal function (eGFR 30 to 60 mL/min/1.73 m).

Mineralocorticoid Receptor Antagonists and Renal Outcomes in Heart Failure Patients with and without Chronic Kidney Disease

INTRODUCTION

The effect of mineralocorticoid receptor antagonists (MRAs) on chronic kidney disease (CKD) progression in patients with heart failure (HF) and with or without preexisting CKD has not been adequately studied.

METHODS

We conducted a retrospective cohort study including consecutive adult patients followed at the HF clinic of a tertiary care center who had already been on an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB). Exposure to MRAs was assessed at 6 months from registration. Patients who were never exposed to an MRA were the control group.

RESULTS

A total of 314 patients who were prescribed an MRA were compared to 1,116 patients who never received an MRA. Among them, 121 and 408 patients, respectively, had CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2). MRAs had to be discontinued in 36/121 patients with CKD (29.8%) and 57/165 patients without CKD (34.5%) (p = 0.39). MRA treatment was associated with a higher risk for persistent creatinine doubling among patients without CKD (hazard ratio 4.07, 95% confidence interval 1.41-11.73). A numerically lower risk was identified among CKD patients (hazard ratio 0.33, 95% confidence interval 0.04-2.78) (p for interaction = 0.009). The primary safety outcome, a composite of any doubling of serum creatinine or any episode of serious hyperkalemia (K+ >6 mmol/L), occurred more commonly in MRA users compared with nonusers in the subgroup of patients without CKD, but not in CKD patients (p for interaction = 0.02).

CONCLUSION

MRA treatment in addition to an ACEI or an ARB could be safely prescribed in HF patients with CKD as it is not associated with persistent renal function decline, acute kidney injury, or serious hyperkalemia, compared with ACEI/ARB monotherapy.

Temporal Trends of Hospitalized Patients with Heart Failure in Korea

Heart failure (HF) is an important cardiovascular disease because of its increasing prevalence, significant morbidity, high mortality and rapidly expanding health care costs. The number of HF patients is increasing worldwide and Korea is no exception. Temporal trends of four representative Korean hospitalized HF registries-the Hallym HF study, the Korean Multicenter HF study, the Korean Heart Failure (KorHF) registry and the Korean Acute Heart Failure (KorAHF) registry showed mild survival improvement reflecting overall HF patient care development in Korea despite the increased severity of enrolled patients with higher incidence of multiple comorbidities. Moreover, device therapies such as implantable cardioverter defibrillator and cardiac resynchronization therapy and definitive treatment such as heart transplantation have been increasing in Korea as well. To prevent HF burden increase, it is essential to set up long term effective prevention strategies for better control of ischemic heart disease, hypertension and diabetes, which might be risk factors for HF development. Moreover, proper HF guidelines, performance measures, and performance improvement programs might be necessary to limit HF burden as well.

Effects of mineralocorticoid receptor antagonists on left ventricular mass in chronic kidney disease patients: a systematic review and meta-analysis

BACKGROUND

Mineralocorticoid receptor antagonists (MRAs) are used widely in treatment of heart failure, but their effects on cardiovascular complications and mortality of chronic kidney disease (CKD) are not well known. Thus, we aim to assess such therapeutic effects of MRAs on CKD.

METHODS

Electronic literature published in any language until Dec 31, 2015, was systematically searched on PubMed, Embase, and Cochrane Central Register of Controlled Trials. Primary outcome was left ventricular mass (LVM) or LVM index (LVMI), and secondary outcome was all-cause mortality and major adverse cardiovascular events (MACEs). Results of continuous outcomes were pooled using mean difference (MD) and standard mean difference (SMD). Risk ratios (RRs) with 95 % confidence intervals (CIs) were pooled using a random- or fixed-effects model.

RESULTS

Totally 12 studies (6 randomized controlled trials with 1003 participants) involving 4935 patients were included. MRA treatment versus non-MRA treatment resulted in a significant change of 0.93 SMD (standard mean difference) in LVM (LVMI), a significant reduction of 22 % in all-cause mortality, a significant reduction of incidence of MACEs (RR 0.65, P = 0.001), significantly higher prevalence rates of hyperkalemia (>5.5 mmol/L), but no significant change in prevalence rates of severe hyperkalemia (>6.0 mmol/L).

CONCLUSION

MRA benefits CKD patients in terms of LVMI, all-cause mortality, and MACEs with no incidence of severe hyperkalemia. Nevertheless, the real effects of MRAs on cardiovascular events and mortality as well as their safety in CKD patients should be identified by further studies with prospective and large-sample clinical trials.