In a patient with heart failure with preserved ejection fraction (HFpEF), grade 1 diastolic dysfunction, normal filling pressures, mild concentric left ventricular hypertrophy, and preserved ejection fraction, should I continue eplerenone 25 mg daily before my upcoming cardiovascular specialist appointment?

Should You Continue Eplerenone Before Your Cardiovascular Specialist Appointment?

You should discontinue eplerenone 25 mg immediately, as mineralocorticoid receptor antagonists are not indicated for HFpEF with grade 1 diastolic dysfunction and normal filling pressures (E/e' ~9). 1

Why Eplerenone Is Not Indicated in Your Case

Evidence-Based Indications for MRAs

The established indications for eplerenone are highly specific and do not match your clinical profile:

• Heart failure with reduced ejection fraction (HFrEF): MRAs are indicated for patients with LVEF ≤35% and NYHA class II-IV symptoms 2, 1
• Post-myocardial infarction: Eplerenone reduces mortality in patients following recent MI with LVEF ≤40% and heart failure symptoms 2, 3
• Resistant hypertension: Eplerenone 50-100 mg daily can be used as an add-on agent 1

Your ejection fraction of 60% with grade 1 diastolic dysfunction and normal filling pressures does not meet any of these criteria. 2, 1

The HFpEF Evidence Gap

• The landmark trials establishing MRA benefit (RALES with spironolactone and EMPHASIS-HF with eplerenone) specifically enrolled patients with LVEF ≤35% 2
• EMPHASIS-HF required either recent cardiovascular hospitalization or elevated natriuretic peptides in addition to reduced ejection fraction 2, 4
• No high-quality evidence supports MRA use in HFpEF with preserved systolic function and normal filling pressures 2, 1

Clinical Reasoning for Discontinuation

Risk-Benefit Analysis

Your clinical scenario presents risks without established benefits:

Risks you face:

• Hyperkalemia, particularly concerning given your concurrent iron supplementation and potential for future RAAS inhibitor therapy 2, 5
• Renal function deterioration (eplerenone requires eGFR monitoring at 3 days, 1 week, then monthly for 3 months) 1, 5
• Gynecomastia or breast tenderness (though less common with eplerenone than spironolactone) 6
• Hypotension 7

Benefits in your case:

• None established by guideline-level evidence for your specific indication 2, 1

The "HFpEF Physiology" Terminology

The term "HFpEF physiology" used by your specialist likely refers to:

• Mild LV concentric hypertrophy (a structural abnormality)
• Grade 1 diastolic dysfunction (mild impairment in relaxation)
• However, with E/e' ~9 (normal filling pressures) and EF 60%, you do not have clinical heart failure 2

Stage B heart failure (structural heart disease without symptoms) does not warrant MRA therapy according to current guidelines. 2, 1

What Should Happen Instead

Appropriate Management for Your Condition

For patients with LV hypertrophy and diastolic dysfunction without heart failure:

• Blood pressure optimization is the primary intervention to prevent progression 2
• ACE inhibitors or ARBs are appropriate for hypertension with LV hypertrophy and may reduce LV mass 2
• Diuretics (if you have hypertension) have been shown to prevent heart failure progression 2
• Beta-blockers may be considered if you have coronary artery disease or hypertension 2

Address Your Iron Deficiency

Your falling ferritin (120 → 18 over 4.5 years) despite oral supplementation requires investigation:

• Iron deficiency without anemia suggests ongoing losses or malabsorption
• This needs evaluation by your cardiovascular specialist, as iron deficiency independently worsens outcomes in heart failure patients
• However, this does not change the lack of indication for eplerenone 1

Action Plan Before Your Appointment

1. Stop eplerenone 25 mg today 1, 5
2. Document the discontinuation and bring this information to your cardiovascular center appointment 5
3. Continue your oral iron supplementation (65 mg plus vitamin C)
4. Prepare questions for your specialist about:
   • The original rationale for starting eplerenone given your preserved EF and normal filling pressures
   • Investigation of your progressive iron deficiency
   • Optimal blood pressure management to prevent LV hypertrophy progression
   • Whether you need any heart failure medications at all given your current status

Common Pitfall to Avoid

Do not confuse "diastolic dysfunction" on an echocardiogram with "heart failure with preserved ejection fraction." 2, 1 Many patients have grade 1 diastolic dysfunction (impaired relaxation) without elevated filling pressures or clinical heart failure. The presence of mild structural changes does not automatically warrant heart failure pharmacotherapy, particularly medications with significant adverse effect profiles like MRAs.

Your upcoming evaluation at a renowned cardiovascular center is the appropriate setting to clarify your diagnosis and establish evidence-based therapy tailored to your actual condition rather than a vague "physiology" descriptor.