The use of spironolactone (Aldacton...

The use of spironolactone (Aldactone) therapy for heart failure increased more than sevenfold after the publication of the randomized ALdactone Evaluation reflection (RALES). The RALES inclusion criteria outlined specific treatment parameters for spironolactone therapy in patients with left ventricular systolic dysfunction and following heart failure, which are similar to popular guidelines (see accompanying table). Although RALES showed a decrease in mortality and hospitalization in patients who met these parameters, spironolactone therapy may cause serious hyperkalemia in patients with marginal renal function, relatively high baseline potassium plains or type IV renal tubular acidosis. It is important to note that RALES exclud patients at high risk of hyperkalemia because of renal insufficiency or diabetes, and patients were below strict surveillance for increasing potassium horizontals and worsening kidney function. These exclusions and continual monitoring do not ruminate usual clinical practice, and there is significant touch about the safety of popular treatment patterns of spironolactone use in the community-based population, particularly in patients with noncardiovascular comorbidities. Masoudi and colleagues studied spironolactone prescription rates after RALES in patients who do not fit the RALES criteria and the resultant complications.

The authors used data from the National Heart Care intend an ongoing initiative funded on Medicare and Medicaid to improve the quality of care for Medicare beneficiaries hospitalized with a principal diagnosis of heart failure. pair cohorts (one from 1998 to 1999 and the other from 2000 to 2001) with a combined population of 19226 patients were rareed Inclusion criteria were age of 65 years or older and ejection fraction les than 40 percent The final patient population included for the most part men with a history of hypertension, coronary artery disease, diabetes, or chronic pulmonary disease.

The research showed that 30.9 percent of patients who did not suitable the RALES criteria received spironolactone. Hyperkalemic-related hospitalizations and mortality increased as well. These increases also occurr in Canada, where spironolactone use increased from 34 to 149 percent with a posterior increase in hyperkalemia-related hospitalizations and mortality.

The authors determine that the increase in hyperkalemic morbidities associated with increasing spironolactone use after RALES hints the need for change in the rife patterns of aldosterone-blocking drug use. However, rALES showed that the use of spironolactone in patients who engage the study's criteria improves morbidity and mortality.

RALES Criteria for Spironolactone Use In Patients with LVSD

Symptoms at pause despite use of digoxin, diuretics, ACE inhibitors, and beta blockers

Serum potassium flush < 5.0 mEq per L (50 mmol by means of L)

Creatinine value < 25 mg by dL (220 [micro]mol per L)

RALES = Randomized ALdactone Evaluation Study;

LVSD = left ventricular systolic dysfunction; ACE = angiotensin-converting enzyme

JILL GIORDANO, Medical Editing leader of responses Georgetown University

Masoudi FA, et al. Adoption of spironolactone therapy for older patients with heart failure and left ventricular systolic dysfunction in the United States, 1998-2001 Circulation July 5 2005;112:39-47

COPYRIGHT 2006 American Academy of Family Physicians

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