Aldosterone use in heart failure

Aldosterone use in heart failure

Aldosterone antagonists are underused in patients with moderate-to-severe heart failure (HF) and systolic dysfunction according to a new study in the Journal of the American Medical Association. Aldosterone antagonists (spironolactone and eplerenone) have been shown to be very effective in the treatment of HF such that they were designated class I (useful and recommended) in the recent American College of Cardiology/American Heart Association Chronic HF Guidelines. Despite this, the drugs are underused in eligible patients.

The current study was an observational analysis of more than 43,000 patients admitted to the hospital with HF and discharged home from 241 hospitals participating in the Get With The Guidelines — HF quality improvement registry between 2005 and 2007. Among 12,565 patients eligible for aldosterone antagonist therapy, only 4087 (32.5%) received one of the drugs at discharge. There was wide variation in aldosterone antagonist usage among hospitals (0%-90.6%) and was more likely to be used in younger patients, African Americans, those with lower blood pressure, history of implantable cardioverter-defibrillator, depression, alcohol use, pacemaker implantation, and those having no history of renal insufficiency. Inappropriate use of aldosterone antagonist therapy was low. The authors conclude that use of aldosterone antagonist therapy is underutilized in HF patients, occurring in only one-third of eligible patients, although the rate of use increased gradually throughout the course of the study. They also state that use of evidence-based guidelines in hospitals may be warranted to improve treatment of HF patients (JAMA 2009;302:1658-1665).

Many clinicians shy away from use of aldosterone antagonists because of concerns regarding hyperkalemia, especially since many of these patients are also on ACE inhibitors or ARBs. Aldosterone inhibitor use in HF is not part of the Joint Commission/Centers for Medicare and Medicaid Services core performance measures. Regardless, aldosterone antagonists have been shown to benefit patients with HF and they are clearly underutilized.