Pharmacological Management

Aldosterone Receptor Antagonists

Patients who have higher aldosterone levels in the first few days after an MI are more likely to experience an adverse in-hospital event (death or a non-fatal cardiovascular event),¹ and have lower 5-year survival,² compared to those with lower levels.

The harmful effects of aldosterone can be attenuated by using an aldosterone receptor antagonist. Eplerenone, a selective aldosterone receptor antagonist, has been shown to significantly reduce all-cause mortality, and deaths or hospitalisations with a cardiovascular cause, in patients with left ventricular dysfunction and evidence of heart failure (or left ventricular dysfunction and diabetes) following MI.³*

Although it is widely used in clinical practice to treat heart failure, spironolactone has not been specifically studied in the post-MI setting.

European guidelines support the use of aldosterone receptor antagonists as adjunctive therapy in patients with left ventricular dysfunction and heart failure (or left ventricular dysfunction without heart failure, if the patient also has diabetes) following MI.^4,5 However, these drugs should not be used in those with significant renal dysfunction or hyperkalaemia.

Potassium levels should be monitored closely in patients receiving aldosterone antagonists.

* Based on EPHESUS trial.³ All patients in EPHESUS had left ventricular dysfunction (defined as a left ventricular ejection fraction ≤40%) following MI and evidence of heart failure, unless they were diabetic, in which case evidence of heart failure was not required for inclusion in the trial.