Spironolactone, a mineralocorticoid receptor antagonist (MRA), has been studied for its efficacy in treating heart failure with preserved ejection fraction (HFpEF).
Efficacy in HFpEF
- The TOPCAT trial, which enrolled patients with left ventricular ejection fraction (LVEF) of 45% or greater, found that spironolactone did not reduce the primary endpoint of cardiovascular death, heart failure hospitalization, or aborted cardiac arrest in patients with HFpEF
- However, the potential efficacy of spironolactone was greatest at the lower end of the LVEF spectrum
- The ESH 2023 guidelines suggest initiating a mineralocorticoid receptor antagonist like spironolactone in the lower HFpEF spectrum, regardless of diagnosed resistant hypertension
Other considerations
- Spironolactone has shown some effectiveness in improving quality of life in HFpEF patients
- The benefit of spironolactone on outcomes could not be solely attributed to potential diuretic effects, suggesting the presence of non-diuretic mechanisms
- Spironolactone improves clinical conditions and prognosis in chronic heart failure and reduces connective tissue matrix turnover
Complications and monitoring
- The use of spironolactone in heart failure should be carefully monitored due to potential complications such as hyperkalemia and renal insufficiency
- Long-term outcome data with respect to safety and utilization of spironolactone in heart failure are not available, and further studies are needed
In conclusion, while spironolactone has shown some potential benefits in HFpEF, its efficacy is more pronounced in patients at the lower end of the LVEF spectrum. Careful monitoring is required due to potential complications, and further studies are needed to fully understand its long-term safety and efficacy in this patient population.