Aldosterone antagonists improve ejection fraction and functional capacity in patients with heart failure irrespective of baseline functional class, a meta-analysis has shown.

This trial, published in Heart, was a meta-analysis of data from 1,575 patients enrolled in 14 prospective randomised controlled trials using aldosterone antagonists. All trials included a clear description of the baseline New York Heart Association (NYHA) classification and change in LV ejection fraction from study initiation to completion.

A mean improvement in ejection fraction of 3.2% and NYHA classification of 0.13 was found in patients treated with aldosterone antagonists when compared with controls (P < 0.001). Furthermore, analysis showed that baseline NYHA class was not predictive of the improvement in ejection fraction (P = 0.67) or NYHA status (P = 0.18).

At present GPs are familiar with the role of aldosterone antagonists in the management of heart failure patients with moderately severe to severe symptoms and systolic heart failure. Symptoms can be objectively classified using the NYHA classification with such patients classed as NYHA III or IV (breathless with minimal activity or at rest). The RALES1 trial has been the cornerstone of this evidence base and as such spironolactone has been a familiar sight on the repeat prescription list of such patients.

More recent evidence from the EMPHASIS-HF2 trial has supported the use of eplerenone in heart failure patients with milder symptoms. Against this background, this meta-analysis has provided further evidence for the early introduction of this class of drugs in patients with heart failure.

The authors of the meta-analysis conclude that aldosterone antagonists are associated with significant improvements in ejection fraction and functional class independent of the baseline functional capacity.

‘The current restriction of aldosterone antagonist use to patients with NYHA class III-IV symptoms should be reconsidered,’ they state.

Considered with the morbidity and mortality data from EMPHASIS these latest findings support the notion that we should be looking to introduce this class of drugs earlier in our heart failure patients and that triple therapy with an ACE inhibitor, beta-blocker and aldosterone antagonist is very much the way forward.

Dr Peter Savill

• Phelan D, Thavendiranathan P, Collier P, Marwick T. Aldosterone antagonists improve ejection fraction and functional capacity independently of functional class: a meta-analysis of randomised controlled trials. Heart 2012;98:1693-1700 doi:10.1136/heartjnl-2012-302178