Aldosterone Antagonists in the Treatment of Heart Failure

Todd R. Marcy; Toni L. Ripley


Am J Health Syst Pharm. 2006;63(1):49-58. 

In This Article

Place in Therapy

In the absence of contraindications, an aldosterone antagonist should be offered to patients with NYHA class III or IV heart failure and to patients after an MI with left ventricular dysfunction. Further studies are needed to confirm the benefit to patients with NYHA class I or II heart failure.

Careful monitoring is critical to prevent potentially life-threatening hyperkalemia. Patients with renal disease, diabetes mellitus, advanced heart failure, or advanced age and those taking certain concurrent medications have the highest risk of developing hyperkalemia. Increased vigilance in monitoring for and patient education regarding hyperkalemic symptoms is necessary in these patients. If baseline CLcr is less than 30 mL/min or baseline serum potassium concentration is greater than 5.5 mmol/L, aldosterone antagonist therapy should be withheld. Recent updates to heart failure guidelines suggest withholding aldosterone antagonist therapy in patients with a baseline serum potassium concentration exceeding 5.0 mmol/L.[1]

Pharmacoeconomic evaluations have found spironolactone and eplerenone to be cost-effective when compared with placebo in the populations studied in the major aldosterone antagonist trials.[90,91] However, no published cost-effectiveness studies have compared spironolactone and eplerenone.

Spironolactone is a life-saving agent in patients with severe heart failure. Eplerenone has been found to be a life-saving agent in patients with left ventricular dysfunction 3–14 days after an MI. No studies have been conducted to establish eplerenone's effects on morbidity and mortality in severe heart failure without a recent MI. Similarly, the effects of spironolactone have not been studied in patients immediately after an MI. Eplerenone appears to have fewer adverse effects than does spironolactone. As such, it is reasonable to substitute eplerenone for spironolactone in patients who develop gynecomastia or adverse sexual effects.