A previous randomized controlled trial evaluating the use of spironolactone in heart failure patients reported a low risk of hyperkalemia (2%) and renal insufficiency (0%). Because treatments for heart failure have changed since the benefits of spironolactone were reported, the prevalence of these complications may differ in current clinical practice. We therefore sought to determine the prevalence and clinical associations of hyperkalemia and renal insufficiency in heart failure patients treated with spironolactone.
We performed a case control study of heart failure patients treated with spironolactone in our clinical practice. Cases were patients who developed hyperkalemia (K(+) >5.0 mEq/L) or renal insufficiency (Cr >or=2.5 mg/dL), and they were compared to 2 randomly selected controls per case. Clinical characteristics, medications, and serum chemistries at baseline and follow-up time periods were compared.
Sixty-seven of 926 patients (7.2%) required discontinuation of spironolactone due to hyperkalemia (n = 33) or renal failure (n = 34). Patients who developed hyperkalemia were older and more likely to have diabetes, had higher baseline serum potassium levels and lower baseline potassium supplement doses, and were more likely to be treated with beta-blockers than controls (n = 134). Patients who developed renal insufficiency had lower baseline body weight and higher baseline serum creatinine, required higher doses of loop diuretics, and were more likely to be treated with thiazide diuretics than controls.
Spironolactone-induced hyperkalemia and renal insufficiency are more common in our clinical experience than reported previously. This difference is explained by patient comorbidities and more frequent use of beta-blockers.
"Hyperkalemia and worsening renal function are serious adverse effects of MRAs, which are contraindicated in such cases according to current guidelines. These events are highly variable and are associated with advanced age, higher baseline potassium levels, decreased baseline renal function, diabetes mellitus and other treatments affecting potassium levels  . Rates of hyperkalemia admissions and mortality were increased following RALES publication , which could also be attributed to the increasing utilization of β-blockers at that time. "
[Show abstract][Hide abstract] ABSTRACT: Following the EPHESUS trial in 2003, mineralocorticoid receptor antagonist (MRA) therapy received a class I indication for the management of eligible high-risk post-MI patients. Our goal was to examine temporal trends in MRA use in eligible post-myocardial infarction (MI) patients.
We investigated temporal trends and factors associated with MRA utilization among eligible patients enrolled in the biannual Acute Coronary Syndrome Israeli Surveys (ACSIS) 2004-2010.
Among 7696 patients enrolled in the ACSIS surveys from 2004, 955 (12%) were eligible for MRA therapy. In this population, prescription of MRAs at discharge from the index event showed a modest increase from 21% to 25% over the six-year period, whereas utilization of other guideline recommended drugs, including angiotensin converting enzyme inhibitors/receptor blockers and β-blockers was >2-fold higher. Multivariate logistic regression analysis showed that independent predictors of MRA prescription at discharge included a higher degree of left ventricular dysfunction (LVEF ≤30% vs. 31-40%: OR=2.19; p=0.02), history of heart failure prior to admission (OR=1.92; p<0.004), admission Killip≥II (OR=1.78; p=0.004), and an anterior location of the index MI (OR=1.54; p=0.03). MRA utilization was not associated with an increased risk for adverse events or rehospitalization at 30days of follow-up.
In a real world setting, approximately one quarter of eligible post-MI patients are treated with an MRA following the index event, without a significant time-dependent change in this management strategy. MRAs are more likely to be underutilized in eligible lower-risk patients.
International journal of cardiology 07/2013; 168(4). DOI:10.1016/j.ijcard.2013.06.091 · 4.04 Impact Factor
"In the EMPHASIS-HF trial, the use of eplerenone reduced the risk of death from a cardiovascular cause or hospitalization for heart failure and these results were not statistically different between the subgroups of patients of older age (24% of the population studied) or less than 75 years. However, in older patients, renal function abnormalities increase the risk of hyperkalemia, as well as of worsening of renal function when spironolactone and eplerenone are administered. As a consequence, serum creatinine and potassium levels should be even more closely monitored in older patients. "
[Show abstract][Hide abstract] ABSTRACT: Chronic heart failure (CHF) represents a major and growing health problem, due to its high incidence and prevalence, its poor prognosis and its impact on health-care costs. Although CHF patients are mainly elderly, few studies were aimed at testing the efficacy of diagnostic and therapeutic approaches in this population. The difficulty in CHF diagnosis among the elderly is related to different factors, such as: the frequent presence of co-morbidity conditions mimicking or masking heart failure signs and symptoms; the different diagnostic cut-offs of natriuretic peptides; and the need to correctly evaluate diastolic function in order to assess CHF with preserved ejection fraction. Furthermore, the therapy of elderly CHF patients has not been well defined, considering the few studies involving very aged patients and the absence of a therapeutic strategy demonstrated to improve prognosis of CHF patients with preserved ejection fraction. The aim of this review is to focus on the most recent issues concerning the diagnosis and therapy of elderly patients affected by CHF.
"A small study suggested that the initiation of beta-blocker therapy was associated with preserved renal function in heart failure patients with a lower baseline GFR but not in those with a higher baseline GFR (22), although these results have yet to be confirmed. Finally, small retrospective studies have suggested that spironolactone may increase creatinine levels (23,24) and should be used cautiously in patients with reduced GFR. "
[Show abstract][Hide abstract] ABSTRACT: Renal dysfunction is common during episodes of acute decompensated heart failure, and historical data indicate that the mean creatinine level at admission has risen in recent decades. Different mechanisms underlying this change over time have been proposed, such as demographic changes, hemodynamic and neurohumoral derangements and medical interventions. In this setting, various strategies have been proposed for the prevention of renal dysfunction with heterogeneous results. In the present article, we review and discuss the main aspects of renal dysfunction prevention according to the different stages of heart failure.
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