What is the role of aldosterone antagonists in the treatment of dilated cardiomyopathy?

Updated: Mar 02, 2021
  • Author: Vinh Q Nguyen, MD, FACC; Chief Editor: Gyanendra K Sharma, MD, FACC, FASE  more...
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Spironolactone acts as an aldosterone receptor blocker and, with concomitant use of angiotensin-converting enzyme (ACE) inhibitors, helps break the cycle of sodium retention and fluid overload via the renin-aldosterone axis. In the Randomized Aldactone Evaluation Study (RALES) (spironolactone vs placebo), the addition of 25 mg of spironolactone daily to a standard treatment regimen for chronic heart failure (CHF) yielded a 35% reduction in hospitalization, significant improvements in New York Heart Association (NYHA) functional class, and a 30% reduction in risk of death. [110]

In the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) (eplerenone vs placebo), the addition of eplerenone to standard therapy resulted in a 15% reduction in all-cause mortality and a 17% reduction in cardiovascular mortality; the combined primary endpoint of cardiovascular (CV) mortality and CV hospitalization was reduced by 13%. EPHESUS was conducted in patients with ejection fractions less than 40% post myocardial infarction and either clinical symptoms of decompensated heart failure or diabetes. [111]

The Emphasis-HF trial noted a 30% reduction in mortality and heart failure hospitalizations when eplerenone was used in addition to standard therapy in patients with class II heart failure who had a left ventricular ejection fraction (LVEF) of less than 35%. However, an increased risk of hyperkalemia was noted, similar to findings from the RALES and EPHESUS trials. [112]

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