Cor Vasa 2011, 53(3):112-117 | DOI: 10.33678/cor.2011.025

Aldosterone antagonists in the treatment of chronic heart failure. Results of the recent EMPHASIS-HF trial

Jiří Widimský

Klinika kardiologie, Institut klinické a experimentální medicíny, Praha, Česká republika

Aldosterone antagonists play an important role in the treatment of NYHA class III and IV chronic heart failure, as shown by the RALES trial in the case of spironolactone. Aldosterone antagonists are also effective in treating patients after acute myocardial infarction and heart failure, as demonstrated by the EPHESUS trial for eplerenone. Recent trials have shown spironolactone to significantly improve left ventricular remodeling and left ventricular diastolic function in stage I and II chronic heart failure.
The EMPHASIS-HF mortality trial has documented the efficacy of eplerenone therapy even in a milder stage of chronic heart failure NYHA class II. The main composite endpoint of the study (a combination of cardiovascular mortality and hospitalization for heart failure) was decreased by as much as 37%, with overall and cardiovascular mortality also significantly reduced, by 24%. Contraindications to therapy include baseline potassium levels ≥ 5 mmol/l, and renal dysfunction (serum creatinine > 250 µmol/l). As hyperkalemia may be the main side effect of aldosterone antagonists, potassium monitoring is absolutely critical to prevent the development of hypokalemia. Caution is to be exercised in elderly patients and those with diabetes. It is currently unclear how often hyperkalemia can occur in patients treated with thiazide as opposed to loop diuretics. The effect of eplerenone seems to be a "class" one as it closely resembles spironolactone action in the more severe forms of heart failure. In clinical practice, it may be appropriate to initiate therapy with spironolactone reserving eplerenone for patients with spironolactone intolerance. This recommendation is due to the different pricing of the two drugs.

Keywords: EMPHASIS-HF; Eplerenone; Mild chronic heart failure

Published: March 1, 2011  Show citation