From the Guidelines
Spironolactone may be considered for patients with heart failure with preserved ejection fraction (HFpEF) and EF 50-55%, particularly in those with evidence of fluid retention or difficulty controlling blood pressure, as it may help reduce hospitalizations for heart failure. The decision to use spironolactone should be individualized based on the patient's symptoms, comorbidities, and risk factors. According to the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1, spironolactone can improve diastolic function in patients with HFpEF. The TOPCAT trial, which studied spironolactone in HFpEF patients, showed a potential benefit in reducing hospitalizations for heart failure, particularly in patients with lower ejection fractions within the preserved range. For patients with EF 50-55%, a typical starting dose would be 12.5 to 25 mg daily, titrated up to a maximum of 50 mg daily as tolerated, while monitoring potassium and renal function. The mechanism of action involves blocking aldosterone, which can reduce fibrosis and improve diastolic function. However, the overall mortality benefit in this specific EF range is not clearly established. When initiating spironolactone, it's crucial to monitor serum potassium and renal function closely, especially in the first few weeks of treatment and after dose adjustments, as recommended by the 2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure 1. Patients should be educated about the potential side effects, including hyperkalemia, gynecomastia in men, and menstrual irregularities in women. Key considerations for the use of spironolactone in HFpEF include:
- Careful monitoring of potassium, renal function, and diuretic dosing at initiation and follow-up to minimize the risk of hyperkalemia and worsening renal function 1
- Selection of patients with symptomatic HFpEF, elevated BNP level or HF admission within 1 year, eGFR >30 mL/min/1.73 m², creatinine <2.5 mg/dL, and potassium <5.0 mEq/L 1
- Individualization of treatment based on patient symptoms, comorbidities, and risk factors.
From the Research
Evidence for Spironolactone in CHF with Preserved EF
- The use of spironolactone in congestive heart failure (CHF) patients with preserved ejection fraction (EF) of 50-55% has been studied, and the evidence suggests that it does not significantly improve cardiac outcomes 2.
- A randomized controlled trial showed that spironolactone did not reduce the incidence of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure in patients with EF > 45% 2.
- Other studies have found that medications, including spironolactone, are not effective in treating heart failure with preserved ejection fraction, except for diuretics 3, 4.
- The current treatment strategies for heart failure with preserved ejection fraction are limited to decongestion by diuretics, promotion of a healthy active lifestyle, and management of comorbidities 4.
- Recent guidelines and reviews provide practical guidance for clinicians on the management of heart failure with preserved ejection fraction, but do not recommend spironolactone as a first-line treatment 5, 6.
Alternative Treatment Options
- Sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, have been shown to reduce HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials 5.
- Diuretics, such as loop diuretics, are recommended for patients with overt congestion to improve symptoms 5, 3.
- Exercise training and diet-induced weight loss have been shown to produce clinically meaningful increases in functional capacity and quality of life in randomized clinical trials 5.