‘It is rarely too late’ to initiate eplerenone for HFrEF
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Key takeaways:
- Eplerenone was beneficial to patients regardless of how long they have had heart failure with reduced ejection fraction.
- “It is rarely too late to consider the initiation of an MRA,” the authors wrote.
Initiation of the nonsteroidal mineralocorticoid receptor antagonist eplerenone shows benefit in patients with HF with reduced ejection fraction, regardless of their disease duration, 1 year or more than 5 years, a speaker reported.
A post hoc analysis of the EMPHASIS-HF trial was presented at the European Society of Cardiology Congress and simultaneously published in the Journal of the American College of Cardiology.
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“Despite robust evidence supporting the benefits of mineralocorticoid receptor antagonists (MRAs) in patients with HFrEF, many patients are not prescribed this treatment. Indeed, MRAs may be more underutilized than any other evidence-based therapy for HFrEF,” Shingo Matsumoto, MD, PhD, of the British Heart Foundation Cardiovascular Research Centre at the University of Glasgow, Scotland, and colleagues wrote in the simultaneous publication. “Physicians may be reluctant to add another treatment in patients with long-standing HF who appear to be stable on their current therapy and are mistakenly thought to be at low risk. This, coupled with safety concerns, may explain the low use of MRAs in many real-world cohorts, particularly in North America.”
To evaluate the efficacy and safety of eplerenone according to chronic HFrEF duration, Matsumoto and colleagues conducted a post hoc analysis of the EMPHASIS-HF trial, which evaluated eplerenone compared with placebo for the reduction of CV death or HF hospitalization.
As Healio previously reported, eplerenone was associated with an approximately 37% reduced risk for CV death or HF hospitalization compared with placebo among patients with HFrEF.
In the EMPHASIS-HF trial, patients were stratified by HFrEF duration: less than 1 year, 1 to 5 years and 5 years or more.
The researchers observed that patients with longer-duration HFrEF were more often older (P < .001) and had a history of comorbidities such as hypertension, ischemic HF, stable angina, MI, CABG, stroke (P for all < .001) and chronic obstructive pulmonary disease (P < .05).
The rate of the primary outcome of CV death or HF hospitalization increased with rising HFrEF duration:
- 9.8 per 1,000 person years for duration less than 1 year (95% CI, 8.4-11.4);
- 13.5 per 1,000 person years for duration 1 to 5 years (95% CI, 11.6-15.7); and
- 17.6 per 1,000 person years for duration 5 years or more (95% CI, 15.6-19.8).
Matsumoto reported that the benefits of eplerenone compared with placebo were consistent across HF duration:
- HR = 0.57 for duration less than 1 year (95% CI, 0.42-0.79);
- HR = 0.81 for duration 1 to 5 years (95% CI, 0.6-1.1); and
- HR = 0.61 for duration 5 years or more (95% CI, 0.48-0.78; P for interaction = .24).
Moreover, the number needed to treat to prevent an occurrence of the primary outcome was 14 for HFrEF duration of 1 year, 13 for 1 to 5 years and 10 for 5 years or more.
“MRAs are one of the most underutilized therapies for HFrEF, especially in North America, despite reducing mortality substantially (only beta-blockers have a similar or larger mortality benefit),” the researchers wrote in JACC. “The present findings mean that it is rarely too late to consider the initiation of an MRA and it can generally be done safely. Even in patients with mild symptoms and long-standing HF, the benefits are significant. These findings support recent efforts to increase the utilization of MRAs.”
Reference:
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Matsumoto S, et al. Insights from recent HFrEF trials 2. Presented at: European Society of Cardiology Congress; Aug. 25-28, 2023; Amsterdam (hybrid meeting).
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