Anti-aldosterone therapy in the treatment of heart failure: new thoughts on an old hormone

Role of mineralocorticoid receptor antagonists in cardiovascular disease

Aldosterone exerts its best known sodium homeostasis actions by controlling sodium excretion at the level of the distal tubules via activation of the apical epithelial sodium channel and the basolateral Na(+)/K(+)ATPase pump. Recently, this mineralocorticoid hormone has been demonstrated to act on the heart and blood vessels. Excess release of aldosterone in relation to the salt status induces both genomic and nongenomic effects that by promoting endothelial dysfunction, and vascular and cardiorenal adverse remodeling, contribute to the target organ damage found in hypertension, heart failure, myocardial infarction, and chronic renal failure. Mineralocorticoid receptor blockers have been shown to be highly effective in resistant hypertension and to slow down heart failure progression, and in experimental animals, the development of atherosclerosis. Blockade of the action of aldosterone and potentially other mineralocorticoid steroids has been increasingly demonstrated to be an extremely beneficial therapy in different forms of cardiovascular disease. This review provides a summary of the knowledge that exists on aldosterone actions in the cardiovascular system and, in providing the translational impact of this knowledge to the clinical arena, illustrates how much more needs to be achieved in exploring the use of mineralocorticoid receptor blockers in less advanced stages of heart, renal, and vascular disease.

Aldosterone, a new appreciation of its role in heart failure

Understanding of the role, triggers, and impact of the renin-angiotensin-aldosterone system in cardiovascular disease has significantly broadened. In recent years substantial discoveries have been made regarding the pathophysiology of heart failure, particularly in the area of neurohormonal activation. New interest in therapy with aldosterone antagonists was stimulated by results of a 2-year study of 1663 patients with heart failure that showed a 30% relative risk reduction of death among patients given a subhemodynamic dosage of spironolactone, a nonselective aldosterone antagonist, compared with placebo, in addition to standard therapy of diuretics, angiotensin-converting enzyme inhibitors, beta-blockers, and digitalis.