title: Effectiveness and Safety of Aldosterone Antagonist Therapy Use Among Older Patients With Reduced Ejection Fraction After Acute Myocardial Infarction.
abstract: BACKGROUND
  While aldosterone antagonists have proven benefit among post-myocardial infarction (MI) patients with low ejection fraction (EF), how this treatment is used among older MI patients in routine practice is not well described.
  
  
  RESULTS
  Using ACTION Registry-GWTG linked to Medicare data, we examined 12 080 MI patients ≥65 years with EF ≤40% who were indicated for aldosterone antagonist therapy per current guidelines and without documented contraindications. Of these, 11% (n=1310) were prescribed aldosterone antagonists at discharge. Notably, 10% of patients prescribed an aldosterone antagonist were eligible for, but not concurrently treated with, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Spironolactone was the predominantly prescribed aldosterone antagonist. At 2-year follow-up, aldosterone antagonist use was not associated with lower mortality (unadjusted 39% versus 38%; HR 0.99, 95% CI 0.88-1.33 using inverse probability-weighted propensity adjustment) except in symptomatic HF patients (HR 0.84, 95% CI 0.72-0.99, Pinteraction=0.009). Risks of hyperkalemia were low at 30 days, but significantly higher among patients prescribed aldosterone antagonists (unadjusted 2.3% versus 1.5%; adjusted HR 2.04, 95% CI 1.16-3.60), as was 2-year risk of acute renal failure (unadjusted 6.7% versus 4.8%; adjusted HR 1.39, 95% CI 1.01-1.92) compared with patients not prescribed aldosterone antagonists.
  
  
  CONCLUSIONS
  Aldosterone antagonist use among eligible older MI patients in routine clinical practice was not associated with lower mortality except in patients with HF symptoms, but was associated with increased risks of hyperkalemia and acute renal failure. These results underscore the importance of close post-discharge monitoring of this patient population.
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W., A.N.V., A.P., E.D.P.).
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W., A.N.V., A.P., E.D.P.).
authors.forename: Amit N
authors.initials: AN
authors.lastname: Vora
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W., A.N.V., A.P., E.D.P.).
authors.forename: S Andrew
authors.initials: SA
authors.lastname: Peng
authors.affiliation: Ahmanson-University of California Los Angeles Cardiomyopathy Center, Los Angeles, CA (G.C.F.).
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, TX (S.D., J.A.L.).
authors.forename: Sandeep
authors.initials: S
authors.lastname: Das
authors.affiliation: University of Texas Southwestern Medical Center, Dallas, TX (S.D., J.A.L.).
authors.forename: James A
authors.initials: JA
authors.lastname: de Lemos
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (T.Y.W., A.N.V., A.P., E.D.P.).
authors.forename: Eric D
authors.initials: ED
authors.lastname: Peterson
mesh_terms: D058186:Acute Kidney Injury / Q000139:chemically induced; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D011307:Drug Prescriptions; D017723:Drug Utilization Review; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D006947:Hyperkalemia / Q000139:chemically induced; D008297:Male; D006278:Medicare; D000451:Mineralocorticoid Receptor Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D009203:Myocardial Infarction / Q000150:complications* / Q000175:diagnosis / Q000401:mortality; D010818:Practice Patterns, Physicians'; D012042:Registries; D018570:Risk Assessment; D012307:Risk Factors; D013148:Spironolactone / Q000009:adverse effects / Q000627:therapeutic use*; D013318:Stroke Volume / Q000187:drug effects*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D000451:Mineralocorticoid Receptor Antagonists; D013148:Spironolactone
keywords: aldosterone antagonist therapy; heart failure; mortality; older population