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Underutilization of MRAs in HFrEF Patients
Quick Takes
- Benefits of eplerenone were consistent across the duration of HF, without an increase in mineralocorticoid receptor antagonist (MRA)-associated adverse events.
- Eplerenone was efficacious and safe in patients with long-standing HFrEF who obtained substantial reductions in mortality and morbidity with this treatment.
- These data suggest that clinicians consider MRA treatment in all patients with HFrEF unless contraindicated, irrespective of the duration of HF.
Study Questions:
What is the safety and efficacy of eplerenone according to duration of heart failure (HF) with reduced ejection fraction (HFrEF)?
Methods:
The investigators created three patient groups according to HFrEF duration: <1 year, ≥1 to <5 years, and ≥5 years in the EMPHASIS-HF trial. The primary outcome was the composite of HF hospitalization or cardiovascular death. Outcomes were adjusted for prespecified prognostic variables and examined by Cox regression models.
Results:
The numbers of patients in each group were: 975 (<1 year), 769 (1-<5 years), and 988 (≥5 years). Patients with longer-standing HF were older and more frequently had cardiovascular/noncardiovascular comorbidities. The rate of the primary outcome (per 100 person-years) increased with HFrEF duration: 9.8 (95% confidence interval [CI], 8.4-11.4) for <1 year, 13.5 (11.6-15.7) for 1-<5 years, and 17.6 (15.6-19.8) for ≥5 years. The benefits of eplerenone were consistent across HF duration: hazard ratio for the primary outcome was 0.57 (95% CI, 0.42- 0.79) for <1 year, 0.81 (0.60-1.10) for 1-<5 years, and 0.61 (0.48-0.78) for ≥5 years; p for interaction = 0.24. The absolute benefit was greatest in the longest duration group: the number needed to treat for the primary outcome was 14 for <1 year, 13 for 1-<5 years, and 10 for ≥5 years in duration.
Conclusions:
The authors report that patients with longer-standing HFrEF had worse clinical status and a higher rate of events, but the benefit of eplerenone was consistent regardless of HFrEF duration.
Perspective:
This study reports that the benefits of eplerenone were consistent across the duration of HF, without an increase in mineralocorticoid receptor antagonist (MRA)-associated adverse events. Eplerenone was efficacious and safe in patients with long-standing HFrEF who obtained substantial reductions in mortality and morbidity with this treatment. These data suggest that clinicians consider MRA treatment in all patients with HFrEF unless contraindicated, irrespective of the duration of HF. There is a need for better understanding of the reasons for underutilization of MRAs in patients with HFrEF to improve care.
Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure
Keywords: Eplerenone, ESC Congress, ESC23, Heart Failure, Mineralocorticoid Receptor Antagonists, Secondary Prevention, Stroke Volume
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