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Agra-Bermejo R, Cordero A, Rodríguez-Mañero M, García Acuña JM, Álvarez Álvarez B, Martínez Á, Álvarez Rodríguez L, Abou-Jokh C, Cid Álvarez B, González-Juanatey JR. Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:652-659. [PMID: 30117745 DOI: 10.1177/2048872618795422] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recent studies suggest that the benefit of mineralocorticoid receptor antagonists in the acute coronary syndrome setting is controversial. The aim of this study was to examine the current long-term prognostic benefit of mineralocorticoid receptor antagonists in patients with acute coronary syndrome. MATERIAL AND METHODS We conducted a retrospective cohort study of 8318 consecutive acute coronary syndrome patients. Baseline patient characteristics were examined and a follow-up period was established for registry of death, major cardiovascular adverse events and heart failure re-hospitalization. We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been treated with mineralocorticoid receptor antagonists. The prognostic value of mineralocorticoid receptor antagonists to predict events during follow-up was analysed using Cox regression. RESULTS Among the study participants, only 524 patients (6.3%) were discharged on mineralocorticoid receptor antagonists. Patients on mineralocorticoid receptor antagonists had a different clinical and pharmacological profile. These differences disappeared after the propensity score analysis. The median follow-up was 40.7 months. After the propensity score analysis, the cardiovascular mortality and heart failure readmission rates were similar between patients who were discharged on mineralocorticoid receptor antagonists and those whose not. The use of mineralocorticoid receptor antagonists was only associated with a reduction in major cardiovascular adverse events (hazard ratio=0.83, 95% confidence interval 0.69-0.97, p=0.001). CONCLUSIONS Our results do not corroborate the long-term benefit of mineralocorticoid receptor antagonists to improve survival after acute coronary syndrome in a large cohort of patients with heart failure or reduced left ventricular ejection fraction and diabetes. Their prescription was associated with a significantly lower incidence of major cardiovascular adverse events during the long-term follow-up without effect on heart failure development.
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Affiliation(s)
- Rosa Agra-Bermejo
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.,Cardiology Department, Hospital Universitario de San Juan, Spain
| | - Moisés Rodríguez-Mañero
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Jose M García Acuña
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Belén Álvarez Álvarez
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Álvaro Martínez
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain
| | | | - Charigan Abou-Jokh
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain
| | - Belén Cid Álvarez
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Jose Ramón González-Juanatey
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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3
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AlShamiri MQ, AlHabib KF, AlHabeeb W, Raslan IR, Ullah A, Elasfar AA, Alshaer F, Albackr H, Mimish L, Almasood A, AlGhamdi S, Ghabashi A. Clinical Presentation, Predictors, and Outcomes Among Mineralocorticoid Receptor Antagonist (MRA)-Eligible Acute Heart Failure Patients in the Heart Function Assessment Registry Trial in Saudi Arabia (HEARTS). Angiology 2018; 69:323-332. [DOI: 10.1177/0003319717720051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Mineralocorticoid receptor antagonist (MRA) therapy is indicated after myocardial infarction in patients with acute heart failure (AHF) with an ejection fraction ≤40% and lacking contraindications. We analyzed clinical presentations, predictors, and outcomes of MRA-eligible patients within a prospective registry of patients with AHF from 18 hospitals in Saudi Arabia, from 2009 to 2010. For this subgroup, mortality rates were followed until 2013, and the clinical characteristics, management, predictors, and outcomes were compared between MRA-treated and non-MRA-treated patients. Of 2609 patients with AHF, 387 (14.8%) were MRA eligible, of which 146 (37.7%) were prescribed MRAs. Compared with non-MRA-treated patients, those prescribed MRAs more commonly exhibited non-ST-segment elevation myocardial infarction, acute on chronic heart failure, past history of ischemic heart disease, and severe left ventricular systolic dysfunction; were more commonly administered oral furosemide and digoxin; and had higher in-hospital recurrent congestive HF rates. Mortality did not significantly differ ( P > .05) between groups. In Saudi Arabia, 37.7% of eligible patients received MRA treatment, which is higher than that in developed countries. The lack of long-term survival benefit raises concerns about systematic problems, for example, proper follow-up and management after hospital discharge, warranting further investigation.
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Affiliation(s)
- Mostafa Q. AlShamiri
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid F. AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Waleed AlHabeeb
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ismail R. Raslan
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Anhar Ullah
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdelfatah A. Elasfar
- King Salman Cardiac Center, King Fahad Medical City, Riyadh, Saudi Arabia
- Cardiology Department, Tanta University, Tanta, Egypt
| | - Fayez Alshaer
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hanan Albackr
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Layth Mimish
- Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Ali Almasood
- Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Saleh AlGhamdi
- Madina Cardiac Center, Al Madina Al Monaoarah, Saudi Arabia
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4
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Bruno N, Sinagra G, Paolillo S, Bonomi A, Corrà U, Piepoli M, Veglia F, Salvioni E, Lagioia R, Metra M, Limongelli G, Cattadori G, Scardovi AB, Carubelli V, Scrutino D, Badagliacca R, Guazzi M, Raimondo R, Gentile P, Magrì D, Correale M, Parati G, Re F, Cicoira M, Frigerio M, Bussotti M, Vignati C, Oliva F, Mezzani A, Vergaro G, Di Lenarda A, Passino C, Sciomer S, Pacileo G, Ricci R, Contini M, Apostolo A, Palermo P, Mapelli M, Carriere C, Clemenza F, Binno S, Belardinelli R, Lombardi C, Perrone Filardi P, Emdin M, Agostoni P. Mineralocorticoid receptor antagonists for heart failure: a real-life observational study. ESC Heart Fail 2018; 5:267-274. [PMID: 29397584 PMCID: PMC5933965 DOI: 10.1002/ehf2.12244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 11/13/2017] [Accepted: 11/14/2017] [Indexed: 11/21/2022] Open
Abstract
Aims Mineralocorticoid receptor antagonists (MRAs) have been demonstrated to improve outcomes in reduced ejection fraction heart failure (HFrEF) patients. However, MRAs added to conventional treatment may lead to worsening of renal function and hyperkalaemia. We investigated, in a population‐based analysis, the long‐term effects of MRA treatment in HFrEF patients. Methods and results We analysed data of 6046 patients included in the Metabolic Exercise Cardiac Kidney Index score dataset. Analysis was performed in patients treated (n = 3163) and not treated (n = 2883) with MRA. The study endpoint was a composite of cardiovascular death, urgent heart transplantation, or left ventricular assist device implantation. Ten years' survival was analysed through Kaplan–Meier, compared by log‐rank test and propensity score matching. At 10 years' follow‐up, the MRA‐untreated group had a significantly lower number of events than the MRA‐treated group (P < 0.001). MRA‐treated patients had more severe heart failure (higher New York Heart Association class and lower left ventricular ejection fraction, kidney function, and peak VO2). At a propensity‐score‐matching analysis performed on 1587 patients, MRA‐treated and MRA‐untreated patients showed similar study endpoint values. Conclusions In conclusion, MRA treatment does not affect the composite of cardiovascular death, urgent heart transplantation or left ventricular assist device implantation in a real‐life setting. A meticulous patient follow‐up, as performed in trials, is likely needed to match the positive MRA‐related benefits observed in clinical trials.
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Affiliation(s)
- Noemi Bruno
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Gianfranco Sinagra
- CardiovascularDepartment, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | | | - Alice Bonomi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Ugo Corrà
- Divisione di Cardiologia Riabilitativa, Istituti Clinici Scientifici Maugeri, Veruno, Italy
| | - Massimo Piepoli
- UOC Cardiologia, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | | | - Rocco Lagioia
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, Cassano delle Murge, Bari, Italy
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Limongelli
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università degli Studi di Napoli, Naples, Italy
| | - Gaia Cattadori
- Unità Operativa Cardiologia Riabilitativa, Multimedica IRCCS, Milan, Italy
| | | | - Valentina Carubelli
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Domenico Scrutino
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, Cassano delle Murge, Bari, Italy
| | - Roberto Badagliacca
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche eGeriatriche, 'Sapienza' University of Rome, Rome, Italy
| | - Marco Guazzi
- Cardiology University Department, Heart Failure Unit and Cardiopulmonary Laboratory, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Rosa Raimondo
- Divisione di Cardiologia Riabilitativa, Istituti Clinici Scientifici Maugeri, Tradate, Italy
| | - Piero Gentile
- CardiovascularDepartment, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | - Damiano Magrì
- Department of Clinical and Molecular Medicine, Azienda Ospedaliera Sant'Andrea, 'Sapienza' Università degli Studi di Roma, Rome, Italy
| | | | - Gianfranco Parati
- Department of Cardiovascular, Neural, and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano, Milan, Italy.,Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Federica Re
- Cardiology Division, Cardiac Arrhythmia Center and Cardiomyopathies Unit, San Camillo-Forlanini Hospital, Rome, Italy
| | | | - Maria Frigerio
- Dipartimento Cardiologico 'A. De Gasperis', Ospedale Cà Granda-A.O. Niguarda, Milan, Italy
| | - Maurizio Bussotti
- Cardiac Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Milan, Italy
| | | | - Fabrizio Oliva
- Dipartimento Cardiologico 'A. De Gasperis', Ospedale Cà Granda-A.O. Niguarda, Milan, Italy
| | - Alessandro Mezzani
- Divisione di Cardiologia Riabilitativa, Istituti Clinici Scientifici Maugeri, Veruno, Italy
| | - Giuseppe Vergaro
- Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy
| | - Andrea Di Lenarda
- Cardiovascular Center, Health Authority n.1 and University of Trieste, Trieste, Italy
| | - Claudio Passino
- Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Susanna Sciomer
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche eGeriatriche, 'Sapienza' University of Rome, Rome, Italy
| | - Giuseppe Pacileo
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università degli Studi di Napoli, Naples, Italy
| | - Roberto Ricci
- Cardiology Division, Santo Spirito Hospital, Rome, Italy
| | | | | | | | | | - Cosimo Carriere
- CardiovascularDepartment, Ospedali Riuniti and University of Trieste, Trieste, Italy
| | | | - Simone Binno
- UOC Cardiologia, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | | | - Carlo Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Michele Emdin
- Fondazione Gabriele Monasterio, CNR-Regione Toscana, Pisa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Deparment of Clinical Sciences and Community Health, Cardiovascular Section, University of Milano, Milan, Italy
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5
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Mineralocorticoid receptor antagonists in patients with acute myocardial infarction - A systematic review and meta-analysis of randomized trials. Am Heart J 2018; 195:60-69. [PMID: 29224647 DOI: 10.1016/j.ahj.2017.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/13/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although mineralocorticoid antagonists (MRAs) reduce mortality in patients with heart failure complicating myocardial infarction (MI), it is unclear if they could be beneficial to all patients with MI. To evaluate the utility of MRAs in MI patients, we performed a systematic review and meta-analysis. METHODS MEDLINE, EMBASE, and Cochrane CENTRAL were searched from 1965 to June 2016. Conference abstracts were searched from 2000 to June 2016. Randomized trials evaluating the effect of MRA after MIs were included. Two reviewers independently extracted data and assessed study quality. Data were combined using fixed-/random-effects models. RESULTS Eleven randomized clinical trials (N = 11,258) were included; 1 trial (N = 6,642) included patients with apparent heart failure (Killip class III-IV). Administration of MRA versus placebo or standard therapy (no-MRA) after MI reduced overall and cardiovascular mortality (odds ratio [OR] 0.82, 95% CI 0.73-0.93, P = .002, and OR 0.82, 95% CI 0.71-0.93, P = .003, respectively; I2 for both = 0%). In the subgroup of trials with patients with heart failure, the mortality was 14.4% in MRA group versus 16.7% in no-MRA group (OR 0.84, 95% CI 0.73-0.96), and among those without heart failure, it was 2.5% with MRA versus 3.5% without MRA (OR 0.72, 95% CI 0.51-1.02, P for interaction = .43). Patients receiving MRA had fewer new or worsening heart failure events (OR 0.74, 95% CI 0.66-0.84, P < .0001; I2 = 14%). Nevertheless, MRA therapy increased risk for hyperkalemia (≥5.5 mmol/L) (OR 2.52, 95% CI 1.36-4.65, P = .003; I2 = 63%). CONCLUSIONS Administration of MRA may reduce mortality after acute MI. However, this is largely based on post-MI patients with heart failure. Further data are needed in MI patients without heart failure.
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