title: Heart failure with systolic dysfunction complicating acute myocardial infarction - differential outcomes but similar eplerenone efficacy by ST-segment or non-ST-segment elevation: A post hoc substudy of the EPHESUS trial.
abstract: BACKGROUND
  Differential outcomes in patients with acute systolic heart failure (HF) complicating acute myocardial infarction (AMI) and the efficacy of mineralocorticoid receptor antagonists according to non-ST-segment and ST-segment elevation myocardial infarction (NSTEMI, STEMI) status has not been specifically investigated.
  
  
  METHODS
  In the EPHESUS study, 6632 patients with acute HF and left ventricular ejection fraction<40% were randomized 3-14 days post-AMI (median 7.3 ± 3.0 days) to receive eplerenone (n=3319) or placebo (n=3313). Among them, 6392 patients with available data on baseline ST-segment status (4634 STEMI; 1758 NSTEMI) were compared using a Cox model analysis stratified according to quintiles of propensity score (PS), taking into account major baseline risk factors, including revascularization.
  
  
  RESULTS
  STEMI and NSTEMI patients differed significantly across a large variety of baseline characteristics. During 30 months of follow-up, all-cause death occurred in 19% and 13% (P<0.0001), cardiovascular death in 16% and 12% (P<0.0001), cardiovascular death and hospitalization in 33% and 26% (P<0.0001) and death from progression of HF in 5% and 3% (P<0.0001) of unadjusted NSTEMI and STEMI patients, respectively. After Cox model PS adjustment without revascularization, NSTEMI status still proved to be a risk factor for all-cause death, cardiovascular death and death from progression of HF. After Cox model PS adjustment including revascularization, none of the outcomes differed between STEMI and NSTEMI patients. Eplerenone morbidity and mortality benefits were consistent in the STEMI and NSTEMI subgroups.
  
  
  CONCLUSIONS
  In patients with acute systolic HF complicating AMI, eplerenone improves outcomes equally in STEMI and NSTEMI patients. Worse outcomes associated with NSTEMI could be explained by more co-morbidities, less aggressive therapies and, mainly, less frequent revascularization.
authors.affiliation: Inserm U961, cardiology, centre d'investigations cliniques CIC9501, institut Lorrain du cœur et des vaisseaux, CHU de Nancy, 2, avenue du Morvan, 54500 Vandoeuvre-Lès-Nancy, France. Electronic address: s.carillo@chu-nancy.fr.
authors.forename: Sylvain
authors.initials: S
authors.lastname: Carillo
authors.affiliation: University of Alabama at Birmingham and VA medical center, Birmingham, AL, USA.
authors.forename: Yan
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Inserm U961, cardiology, centre d'investigations cliniques CIC9501, institut Lorrain du cœur et des vaisseaux, CHU de Nancy, 2, avenue du Morvan, 54500 Vandoeuvre-Lès-Nancy, France.
authors.forename: Renaud
authors.initials: R
authors.lastname: Fay
authors.affiliation: Clinic Louis-Pasteur, 54270 Essey-Lès-Nancy, France.
authors.forename: Michael
authors.initials: M
authors.lastname: Angioi
authors.affiliation: Pfizer Inc., New York City, NY, USA.
authors.forename: John
authors.initials: J
authors.lastname: Vincent
authors.affiliation: Pfizer Inc., New York City, NY, USA.
authors.forename: Santosh C
authors.initials: SC
authors.lastname: Sutradhor
authors.affiliation: University of Alabama at Birmingham and VA medical center, Birmingham, AL, USA.
authors.forename: Ali
authors.initials: A
authors.lastname: Ahmed
authors.affiliation: University of Michigan, Ann Arbor, MI, USA.
authors.forename: Bertram
authors.initials: B
authors.lastname: Pitt
authors.affiliation: Inserm U961, cardiology, centre d'investigations cliniques CIC9501, institut Lorrain du cœur et des vaisseaux, CHU de Nancy, 2, avenue du Morvan, 54500 Vandoeuvre-Lès-Nancy, France.
authors.forename: Faiez
authors.initials: F
authors.lastname: Zannad
mesh_terms: D000368:Aged; D002317:Cardiovascular Agents / Q000627:therapeutic use; D002318:Cardiovascular Diseases / Q000401:mortality; D002423:Cause of Death; D015897:Comorbidity; D003328:Coronary Thrombosis / Q000150:complications; D018450:Disease Progression; D004562:Electrocardiography; D000077545:Eplerenone; D005260:Female; D006333:Heart Failure / Q000188:drug therapy* / Q000209:etiology / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D000451:Mineralocorticoid Receptor Antagonists / Q000627:therapeutic use*; D015337:Multicenter Studies as Topic / Q000706:statistics & numerical data; D009203:Myocardial Infarction / Q000145:classification / Q000150:complications* / Q000503:physiopathology / Q000601:surgery; D009204:Myocardial Revascularization; D011379:Prognosis; D016016:Proportional Hazards Models; D016032:Randomized Controlled Trials as Topic; D012189:Retrospective Studies; D013148:Spironolactone / Q000031:analogs & derivatives* / Q000627:therapeutic use; D016896:Treatment Outcome
chemical_list: D002317:Cardiovascular Agents; D000451:Mineralocorticoid Receptor Antagonists; D013148:Spironolactone; D000077545:Eplerenone
keywords: Eplerenone; Heart failure; IDM ST+; IDM ST–; Insuffisance cardiaque; NSTEMI; STEMI; Éplérénone