Evidence-based Management of Post-Acute Myocardial Infarction Heart Failure - The Role of Aldosterone Blockade

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Citation
US Cardiology 2004;2004:1(1):1-4

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Introduction

Clinical heart failure is a common complication of acute myocardial infarction (AMI), affecting approximately 30% of these patients.1,2 This complication of AMI leads to significantly increased risk for mortality and morbidity post-AMI. The presence of heart failure after AMI significantly decreases both early and long-term survival compared to AMI patients without heart failure.1,3,4 It is associated with in-hospital mortality rates of 12% to 24%, which represent a two- to four-fold increased risk of dying during hospitalization for AMI among patients with heart failure compared to those without heart failure.2-5 Heart failure on admission for AMI is also associated with a marked increase in mortality rates at six months post-discharge (8.5% vs 2.8% [with vs without heart failure], P<0.0001).3 In addition, post-AMI patients with heart failure have longer lengths of AMI hospital stay3,4 and higher readmission rates3 than those with no heart failure. These patients also experience a higher incidence of recurrent MI, stroke, second- or third-degree atrioventricular (AV) block, ventricular arrhythmias, and cardiac rupture during hospitalization compared to those without heart failure.4

Eplerenone (Inspra®) is a selective aldosterone blocker indicated to improve survival of stable patients with left ventricular systolic dysfunction (LVSD) (ejection fraction <_40%) and clinical evidence of heart failure after an AMI.6 It is the only aldosterone blocker indicated to improve survival, and the only one studied in the post-AMI setting.

The new American College of Cardiology/American Heart Association (ACC/AHA) practice guidelines for the management of patients with ST-segment elevation myocardial infarction (STEMI) include a class IA recommendation for the in-hospital initiation and long-term use of aldosterone blockade for STEMI patients with a left ventricular ejection fraction <_40% who have either symptoms of heart failure or diabetes and who are receiving angiotensin-converting enzyme [ACE] inhibitor therapy.7 However, because current therapeutic guidelines do not include specific information for the practical use of eplerenone in patients with post-AMI heart failure, an evidence-based medicine approach using data and results from the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) can be used to guide clinicians in the practical, clinical utilization of eplerenone therapy.8

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References
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  8. Pitt B, Remme W, Zannad F, et al., for the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators, “Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction”, N. Engl. J. Med. (2003), 348: pp. 1,309–1,321.
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  9. The Merck Manual of Diagnosis and Therapy [online]. Section 2. Endocrine and metabolic disorders. Chapter 12.Water, electrolyte, mineral, and acid-base metabolism; Potassium metabolism. Available at: http://www.merck.com/mrkshared/mmanual/section2/ chapter12/12c.jsp.Accessed August 5, 2004.