Aldosterone Antagonists Improved Survival in STEMI Without Heart Failure
Aldosterone antagonist therapy resulted in a greater increase in LVEF compared with control.
In patients with ST-segment elevation myocardial infarction (STEMI) and left ventricular ejection fraction (LVEF) >40%, the use of aldosterone antagonists is associated with a significant reduction in mortality, according to findings from a meta-analysis published in JAMA Internal Medicine.
Study investigators selected 10 randomized clinical trials that included unique patients with STEMI without clinical heart failure (HF) or an LVEF >40% (N=4147). All participants had been treated with aldosterone antagonists and had survival outcomes available for assessment. The major outcomes and measures of the analysis included mortality, myocardial infarction (MI), new congestive heart failure (CHF), ventricular arrhythmia, change in LVEF, serum creatinine level, and potassium level.
In 9 studies that included a control group, the use of aldosterone antagonists in STEMI participants without HF was associated with a significantly reduced risk for mortality (2.4% vs 3.9%, respectively; odds ratio [OR], 0.62; 95% CI, 0.42-0.91; P =.01). Aldosterone antagonists did not significantly reduce the risk for MI (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; P =.91), CHF (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; P =.31), or ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; P =.33) compared with control.
In addition, aldosterone antagonist therapy resulted in a greater increase in LVEF compared with control (mean difference, 1.58%; 95% CI, 0.18%-2.97%; P =.03), as well as a small yet significant increase in the serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; P =.02). No significant changes were found between treatment and control groups in terms of the serum creatinine level (standardized mean difference, 1.4; 95% CI, −0.43 to 3.24; P =.13).
A limitation of the analysis included the investigators' inability to adjust for variations among studies, including the route of aldosterone antagonist therapy (oral vs intravenous), follow-up durations, and the use of concomitant therapies.
The findings highlight the potential benefit of using aldosterone antagonists in this patient population, considering "STEMI and its adverse effects on morbidity and mortality remain major cardiovascular problems, and there is a constant search for therapies to improve survival and other clinical outcomes."
Dahal K, Hendrani A, Sharma SP, et al. Aldosterone antagonist therapy and mortality in patients with ST-segment elevation myocardial infarction without heart failure: a systematic review and meta-analysis [published online May 21, 2018]. JAMA Intern Med. doi:10.1001/jamainternmed.2018.0850