Should MRAs be at the front row in heart failure? A plea for the early use of mineralocorticoid receptor antagonists in medical therapy for heart failure based on clinical experience.
The brand new 2016 ESC guidelines for the treatment of acute and chronic heart failure continue to give a prominent place to mineralocorticoid receptor antagonists in the treatment of chronic heart failure with reduced ejection fraction (HFrEF). In the prevention of HF hospitalization and death, a class I, level of recommendation A, is given to MRAs for patients with HFrEF, who remain symptomatic despite treatment with an ACE-inhibitor and a beta-blocker and have an LVEF below 35 %. This recommendation is primarily based on two landmark trials, the RALES trial (for spironolactone) and the EMPHASIS-HF trial (for eplerenone). A crucial question is, however, why MRAs are advised only in "third place," i.e., after optimal up-titration of ACE-inhibitors and beta-blockers. We wonder whether MRAs could not or should not be given earlier in the treatment of HFrEF, namely before or together with the up-titration of ACE-inhibitors and beta-blockers. Several arguments to support this plea are described in this short paper.
Cardiovascular Center, OLV Ziekenhuis Aalst, Moorselbaan 164, 9300, Aalst, Belgium. ward.heggermont@olvz-aalst.be.
Ward A
0000-0002-5368-2223
WA
Heggermont
Cardiovascular Center, OLV Ziekenhuis Aalst, Moorselbaan 164, 9300, Aalst, Belgium.
Marc
M
Goethals
Cardiovascular Center, OLV Ziekenhuis Aalst, Moorselbaan 164, 9300, Aalst, Belgium.
Riet
R
Dierckx
Cardiovascular Center, OLV Ziekenhuis Aalst, Moorselbaan 164, 9300, Aalst, Belgium.
Sofie
S
Verstreken
Cardiovascular Center, OLV Ziekenhuis Aalst, Moorselbaan 164, 9300, Aalst, Belgium.
Jozef
J
Bartunek
Cardiovascular Center, OLV Ziekenhuis Aalst, Moorselbaan 164, 9300, Aalst, Belgium.
Marc
M
Vanderheyden
D000077545:Eplerenone; D006333:Heart Failure / Q000188:drug therapy*; D006801:Humans; D000451:Mineralocorticoid Receptor Antagonists / Q000627:therapeutic use*; D017410:Practice Guidelines as Topic; D013148:Spironolactone / Q000031:analogs & derivatives / Q000627:therapeutic use; D013318:Stroke Volume
D000451:Mineralocorticoid Receptor Antagonists; D013148:Spironolactone; D000077545:Eplerenone
Eplerenone; Heart failure guidelines; Mineralocorticoid receptor antagonist; Spironolactone