Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis
Restricted accessResearch articleFirst published online October, 2019
Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis
Recent studies suggest that the benefit of mineralocorticoid receptor antagonists in the acute coronary syndrome setting is controversial. The aim of this study was to examine the current long-term prognostic benefit of mineralocorticoid receptor antagonists in patients with acute coronary syndrome.
Material and methods:
We conducted a retrospective cohort study of 8318 consecutive acute coronary syndrome patients. Baseline patient characteristics were examined and a follow-up period was established for registry of death, major cardiovascular adverse events and heart failure re-hospitalization. We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been treated with mineralocorticoid receptor antagonists. The prognostic value of mineralocorticoid receptor antagonists to predict events during follow-up was analysed using Cox regression.
Results:
Among the study participants, only 524 patients (6.3%) were discharged on mineralocorticoid receptor antagonists. Patients on mineralocorticoid receptor antagonists had a different clinical and pharmacological profile. These differences disappeared after the propensity score analysis. The median follow-up was 40.7 months. After the propensity score analysis, the cardiovascular mortality and heart failure readmission rates were similar between patients who were discharged on mineralocorticoid receptor antagonists and those whose not. The use of mineralocorticoid receptor antagonists was only associated with a reduction in major cardiovascular adverse events (hazard ratio=0.83, 95% confidence interval 0.69–0.97, p=0.001).
Conclusions:
Our results do not corroborate the long-term benefit of mineralocorticoid receptor antagonists to improve survival after acute coronary syndrome in a large cohort of patients with heart failure or reduced left ventricular ejection fraction and diabetes. Their prescription was associated with a significantly lower incidence of major cardiovascular adverse events during the long-term follow-up without effect on heart failure development.
SmolinaKWrightFlRaynerM, et al. Long-term survival and recurrence after acute myocardial infarction in England, 2004 to 2010. Circ Cardiovasc Qual Outcomes2012; 5: 532–540.
2.
RoffiMPatronoCColletJP, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J2016; 37: 267–315.
3.
IbanezBJamesSAgewallS, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the Management of Acute Myocardial Infarction in Patients Presenting with ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J2018; 39: 119–177.
4.
BeyguiFColletJ-PBenolielJ-J, et al. High plasma aldosterone levels on admission are associated with death in patients presenting with acute ST-elevation myocardial infarction. Circulation2006; 114: 2604–2610.
5.
PalmerBRPilbrowAPFramptonCM, et al. Plasma aldosterone levels during hospitalization are predictive of survival post-myocardial infarction. Eur Heart J2008; 29: 2489–2496.
6.
BeyguiFSilvainJPenaA, et al. Usefulness of biomarker strategy to improve GRACE score’s prediction performance in patients with non–ST segment elevation acute coronary syndrome and low event rates. Am J Cardiol2010; 106: 650–658.
7.
PerrierEKerfantB-GLaleveeN, et al. Mineralocorticoid receptor antagonism prevents the electrical remodeling that precedes cellular hypertrophy after myocardial infarction. Circulation2004; 110: 776–783.
8.
PittBRemmeWZannadF, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med2003; 348: 1309–1321.
9.
Montalescot G, Pitt B, Lopez de Sa E, et al; REMINDER Investigators. Early eplerenone treatment in patients with acute ST elevation myocardial infarction without heart failure: The Randomized Double-Blind Reminder Study. Eur Heart J2014; 35: 2295–2302.
10.
BeyguiFCaylaGRouleV, et al. Early aldosterone blockade in acute myocardial infarction: The Albatross Randomized Clinical Trial. J Am Coll Cardiol2016; 67: 1917–1927.
11.
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis2002; 39: 1–266.
12.
AmsterdamEAWengerNKBrindisRG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol2014; 64: E139–E228.
13.
BodenWEO’RourkeRATeoKK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med2007; 356: 1503–1516.
14.
IqbalJZhangYJHolmesDR, et al. Optimal medical therapy improves clinical outcomes in patients undergoing revascularization with percutaneous coronary intervention or coronary artery bypass grafting: Insights from the Synergy Between Percutaneous Coronary Intervention With Taxus And Cardiac Surgery (SYNTAX) trial at the 5-year follow-up. Circulation2015; 131: 1269–1277.
15.
GrangerCBGoldbergRJDabbousO, et al. Predictors of hospital mortality in the Global Registry of Acute Coronary Events. Arch Intern Med2003; 163: 2345–2353.
16.
SubherwalSBachRGChenAY, et al. Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) bleeding score. Circulation2009; 119: 1873–1882.
17.
CorderoARodriguez-ManeroMGarcía-AcuñaJM, et al. Additive value of the CRUSADE score to the GRACE score for mortality risk prediction in patients with acute coronary syndromes. Int J Cardiol2017; 245: 1–5.
18.
Galvao BragaCCid-AlvarezABRedondo DieguezA, et al. Multivessel versus culprit-only percutaneous coronary intervention in ST-segment elevation acute myocardial infarction: Analysis of an 8-year registry. Rev Esp Cardiol (Engl Ed)2017; 70: 425–432.
19.
FineJPGrayRJ.A proportional hazards model for the subdistribution of a competing risk. J Am Stat Assoc1999; 94: 496–509.
20.
RaoKKEnriquezJRDe LemosJA, et al. Use of aldosterone antagonists at discharge after myocardial infarction: Results from the National Cardiovascular Data Registry Acute Coronary Treatment And Intervention Outcomes Network (ACTION) Registry–Get With the Guidelines (GWTG). Am Heart J2013; 166: 709–715.
21.
KoifmanEKopelEMaorE, et al. Mineralocorticoid receptor antagonist use in eligible patients following acute myocardial infarction: Real world data from the acute coronary syndrome Israeli surveys: 2004–2010. Int J Cardiol2013; 168: 3971–3976.
22.
BossardMBinbraikYBeyguiF, et al. Mineralocorticoid receptor antagonists in patients with acute myocardial infarction – a systematic review and meta-analysis of randomized trials. Am Heart J2018; 195: 60–69.
23.
BozkurtBAgostonIKnowltonAA.Complications of inappropriate use of spironolactone in heart failure: When an old medicine spirals out of new guidelines. J Am Coll Cardiol2003; 41: 211–214.
24.
JuurlinkDNMamdaniMMLeeDS, et al. Rates of hyperkalemia after publication of the randomized aldactone evaluation study. N Engl J Med2004; 351: 543–551.
25.
ShahKBRaoKSawyerR, et al. The adequacy of laboratory monitoring in patients treated with spironolactone for congestive heart failure. J Am Coll Cardiol2005; 46: 845–849.
26.
SarwarCMPapadimitriouLPittB, et al. Hyperkalemia in heart failure. J Am Coll Cardiol2016; 68: 1575–1589.
27.
DicksteinKCohen-SolalAFilippatosG, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J2008; 29: 2388–2442.
28.
HuntSAAbrahamWTChinMH, et al. Focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults. A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines developed in collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol2009; 53: e1–e90.
29.
WeirRAMarkPBPetrieCJ, et al. Left ventricular remodeling after acute myocardial infarction: Does eplerenone have an effect?Am Heart J2009; 157: 1088–1096.
30.
LeH-HEl-KhatibCMombledM, et al. Impact of aldosterone antagonists on sudden cardiac death prevention in heart failure and post-myocardial infarction patients: A systematic review and meta-analysis of randomized controlled trials. PLoS One2016; 11: e0145958.
31.
Al ShamiriMQAl HabibKFAl HabeebW, et al. Clinical presentation, predictors, and outcomes among mineralocorticoid receptor antagonist (MRA)-eligible acute heart failure patients in the Heart Function Assessment Registry Trial in Saudi Arabia (HEARTS). Angiology 2018; 69: 323–332.
32.
TomasevicDEl KhouryCSubtilF, et al. Effect of optimal medical therapy at discharge in patients with reperfused ST-segment elevation myocardial infarction on 1-year mortality (from the Regional RESCUe Registry). Am J Cardiol2018; 121: 403–409.
33.
Alonso SalinasGLSanmartin FernandezM, et al. Frailty predicts major bleeding within 30 days in elderly patients with acute coronary syndrome. Int J Cardiol2016; 222: 590–593.
34.
CorderoALopez-PalopRCarrilloP, et al. Changes in acute coronary syndrome treatment and prognosis after implementation of the infarction code in a hospital with a cardiac catheterization unit. Rev Esp Cardiol (Engl Ed)2016; 69: 754–759.
35.
Ruiz-NodarJMGomez-SansanoJMGalceraE, et al. Evaluation of a ’color coding’ system for the assessment of patients undergoing primary percutaneous coronary intervention. Int J Cardiol2016; 212: 371–376.
