{"id":4631,"date":"2010-11-16T11:17:57","date_gmt":"2010-11-16T16:17:57","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/?p=4631"},"modified":"2011-07-19T17:45:12","modified_gmt":"2011-07-19T21:45:12","slug":"putting-the-emphasis-on-eplerenone-for-hf","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2010\/11\/16\/putting-the-emphasis-on-eplerenone-for-hf\/","title":{"rendered":"Putting the EMPHASIS on Eplerenone for HF"},"content":{"rendered":"

In the EMPHASIS-HF study<\/a>, aldosterone inhibition with eplerenone reduced the rate of death from cardiovascular causes or heart-failure (HF) hospitalizations by about 37% (compared with placebo) in patients with functional NHYA class II HF. CardioExchange welcomes Paul Armstrong, Professor of Medicine in the Division of Cardiology at the University of Alberta, to answer our questions about this study. His editorial<\/a> on the EMPHASIS-HF study appears in the <\/em>New England Journal of Medicine.<\/em><\/p>\n

The Data Safety and Monitoring Committee terminated the study early.\u00a0 How would you respond to those that point out that this often exaggerates the treatment effects?<\/strong><\/p>\n

The results of EMPHASIS-HF are so clearly positive and consistent with prior work that I suspect this was a minimal issue in the decision to end the study early.<\/p>\n

Few patients <\/strong>(about 20%) <\/strong>in EMPHASIS-HF were treated with an implantable cardiodefibrillator (ICD) or cardiac resynchronization therapy (CRT). Would you expect such therapy to blunt the benefits of eplerenone?\u00a0 Should we restrict aldosterone inhibitor therapy to patients without ICD or CRT therapy?<\/strong><\/p>\n

Device implantation might have blunted some of the effect, but by no means all in my view. A future study might usefully explore whether device therapy can improve outcomes on top of eplerenone.<\/p>\n

Although the trial purportedly studied patients with \u201cmild\u201d (NHYA class II) HF, they appeared to have advanced disease (mean LVEF, 26%).\u00a0 Should patients with moderately reduced EF (30-50%) be treated with an aldosterone inhibitor?<\/strong><\/p>\n

We will need to see from additional analysis the extent to which baseline EF interacted with treatment effect, but I would guess that anyone with a depressed EF would benefit from this therapy. I recall that the EPHESUS trial showed a benefit for post-MI HF patients with an EF mean of 33%. The diastolic dysfunction among patients with normal EFs are the subject of ongoing studies.<\/p>\n

Following the RALES trial, widespread use of spironolactone in HF patients resulted in an increased incidence of hyperkalemia and cardiac-related death.\u00a0 Should we expect the same with eplerenone?<\/strong><\/p>\n

It has recently been shown<\/a> that careful monitoring of renal function and electrolytes is warranted and this results in safer general use. I believe the Ontario data published in NEJM<\/em><\/a> may have overstated the safety issue.<\/p>\n

In the editorial that accompanied the study, you recommended that spironolactone be used in HF patients and the more expensive eplerenone be reserved for the rare patient who has disabling side effects from spironolactone.\u00a0 Are there any differences in efficacy or safety between the two?<\/strong><\/p>\n

The principal side effect of aldosterone is painful gynecomastia, which occurs in about 10% of men and can be avoided with eplerenone. There is not a direct head-to-head comparison of these antagonists: However, based on what literature is available, I believe they are otherwise very similar regarding their safety and efficacy.<\/p>\n","protected":false},"excerpt":{"rendered":"

In the EMPHASIS-HF study, aldosterone inhibition with eplerenone reduced the rate of death from cardiovascular causes or heart-failure (HF) hospitalizations by about 37% (compared with placebo) in patients with functional NHYA class II HF. CardioExchange welcomes Paul Armstrong, Professor of Medicine in the Division of Cardiology at the University of Alberta, to answer our questions […]<\/p>\n","protected":false},"author":154,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1],"tags":[],"class_list":["post-4631","post","type-post","status-publish","format-standard","hentry","category-general"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/4631","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/154"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=4631"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/4631\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=4631"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=4631"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=4631"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}