The use of angiotensin-converting e...

The use of angiotensin-converting enzyme (ACE) inhibitors to treat patients with heart failure is standard practice. The addition of spironolactone for aldosterone blockade in patients already receiving ACE inhibitors has been shown to provide further benefits in risk reduction of death and rates of hospitalization. Pitt and other investigators from the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival consideration (EPHESUS) conducted a randomized, double-blinded, placebo-controlled contemplation of eplerenone in patients with acute myocardial infarction complicated from left ventricular dysfunction and heart failure.

This international trial registered 6,642 patients three to 14 days after acute myocardial infarction if they had the following: left ventricular dysfunction and ejection fraction of 40 percent or lower in succession echocardiography, radionuclide angiography, or angiography of the left ventricle; and clinical evidence of heart failure, of the like kind as pulmonary rales, chest radiograph exhibiting pulmonary venous congestion, or demeanor of a third heart perfect All patients received standard medical therapy after infarction, including ACE inhibitors, angiotensin-receptor blocker diuretics, beta blocker and coronary revascularization, as indicated. Patients were exclud if they were already using potassium-sparing diuretics or if they had a serum creatinine concentration of more than 25 mg by dL (220 [mu]mol per L) or a serum potassium concentration of more than 5 mEq for L (5 mmol per L) The number of exclud patients was not given.

Participants were randomized to receive eplerenone, 25 mg daily, or matching placebo. After four weeks, the dosage of eplerenone was increased to a maximum of 50 mg daily, if tolerated. Whenever a patient had a serum potassium concentration of more than 55 mEq through L (5.5 mmol per L) the reflection drug was reduced or discontinued until the serum potassium concentration cut down below this cutoff value. Follow-up occurr at weeks 1 and 4 three month and each three months until the expiration of the study. The mean follow-up time was 16 months

The primary issue for the study was death from all causes, which occurr in 478 patients (144 percent) receiving eplerenone and 554 patients (167 percent) receiving placebo; this was a statistically significant reduction. Other issue measures also showed small benefits associated with the use of eplerenone, including death from cardiovascular causes, hospitalization rates, and unforeseen death.

Discontinuation of the contemplation medication was fairly high; 528 patients (159 percent) receiving eplerenone and 493 patients (149 percent) receiving placebo discontinued their randomly assigned medication. Serious hyperkalemia (defined as a serum potassium concentration of at least 6 mEq by L [6 mmol per L]) occurr in 180 patients (55 percent) receiving eplerenone and 126 patients (39 percent) receiving placebo.

The authors close that adding the aldosterone blocker eplerenone to the standard treatment of patients with acute myocardial infarction complicated by dint of left ventricular dysfunction and heart failure improves their survival and hospitalization rates.

Bill Zepf MD

Pitt B et al. Eplerenone, a selective aldosterone blocker in patients with left ventricular dysfunction after myocardial infarction. N Engl J M April 3 2003;348:1309-21

Editor's Note: The statistically significant, on the other hand clinically modest, reduction in overall mortality seen with the use of eplerenone translates to a "number of patients destitutioned to treat" of 43. Treating 43 patients with heart failure for a year and a half with an inexpensive aldosterone blocker in the same state [i]or[/i] condition as spironolactone, to prevent undivided death would seem reasonable to many, although the list of "must-have" medications for patients with heart failure is getting quite extended Whether one can make a similar case for an expensive alternative aldosterone blocker with a les well-known safety profile, as it was as eplerenone, is more difficult to discern.--b.z.

COPYRIGHT 2003 American Academy of Family Physicians

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