In a 72‑year‑old man with preserved left‑ventricular ejection fraction (~60 %), grade 1 diastolic dysfunction, normal filling pressures, mild concentric LV hypertrophy, no shortness of breath, minimal fatigue, normal hemoglobin, excellent exercise capacity (Bruce stage 4), and only mild venous foot/ankle edema and abdominal fullness, is there any justification to continue eplerenone, or should it be stopped?

Should You Discontinue Eplerenone?

Yes, you should discontinue eplerenone—there is no evidence-based indication for this medication in your clinical scenario. You have preserved ejection fraction (~60%), grade 1 diastolic dysfunction with normal filling pressures, no heart failure symptoms (no shortness of breath, minimal fatigue), and excellent functional capacity (Bruce Protocol stage 4). 1

Why Eplerenone Is Not Indicated in Your Case

Established Indications for Eplerenone

• Eplerenone is FDA-approved and guideline-supported only for heart failure with reduced ejection fraction (HFrEF, LVEF ≤40%) following acute myocardial infarction, or for symptomatic chronic HFrEF. 2, 3
• The landmark EPHESUS trial demonstrated mortality benefit specifically in post-MI patients with LVEF ≤40% and clinical heart failure symptoms—a population entirely different from yours. 2, 3

Lack of Evidence in Preserved Ejection Fraction

• In heart failure with preserved ejection fraction (HFpEF, LVEF ≥50%), mineralocorticoid receptor antagonists like eplerenone have shown only modest reduction in hospitalizations without mortality benefit. The TOPCAT trial found a hazard ratio of 0.83 for HF hospitalizations but failed to meet its primary composite endpoint. 1
• Even in HFpEF, spironolactone (not eplerenone) is considered only a Class IIb recommendation (may be considered), and only in patients with symptomatic heart failure requiring hospitalization reduction. 1

Your Clinical Profile Does Not Meet Criteria

• You do not have heart failure. Your preserved LVEF of 60%, normal filling pressures, and Bruce Protocol stage 4 performance indicate excellent cardiac function. 1
• Grade 1 diastolic dysfunction with normal filling pressures is a common age-related finding and does not constitute heart failure in the absence of symptoms or elevated natriuretic peptides. 4
• Your mild ankle edema is attributed to venous insufficiency—a non-cardiac cause that does not respond to aldosterone antagonists. 1

Evidence Against Use in Your Population

• A 2016 randomized controlled trial specifically tested eplerenone 25 mg daily in coronary artery disease patients with preserved ejection fraction (similar to your profile). The study found no improvement in endothelial function, blood pressure, or any vascular health markers compared to placebo. 5
• This negative trial helps explain why eplerenone has no role in patients like you who have preserved systolic function without heart failure symptoms. 5

What Your Providers Should Focus On Instead

Blood Pressure Management

• Your metoprolol ER 100 mg may be insufficient if blood pressure remains above target (<130/80 mmHg for someone with mild LV hypertrophy). Consider titrating metoprolol to 200 mg daily or adding an ACE inhibitor/ARB as first-line antihypertensive therapy. 1
• ACE inhibitors or ARBs are the preferred first-line agents for hypertension in patients with diastolic dysfunction and LV hypertrophy. 1

Addressing Your Actual Symptoms

• Mild foot/ankle edema from venous insufficiency requires compression stockings and leg elevation, not cardiac medications. 1
• Your abdominal fullness warrants evaluation for non-cardiac causes (gastrointestinal, hepatic, or other intra-abdominal pathology) rather than treatment with diuretics or aldosterone antagonists. 1

Monitoring Considerations

• Discontinuing eplerenone eliminates the risk of hyperkalemia, which is particularly important if you ever need to start an ACE inhibitor or ARB for blood pressure control. 1
• Your low-normal hemoglobin (13 g/dL range) should be monitored, as anemia can contribute to fatigue and may warrant separate evaluation. 1

Bottom-Line Statement for Your Provider

"I request discontinuation of eplerenone because I have preserved ejection fraction (60%), no heart failure symptoms, excellent exercise capacity (Bruce stage 4), and normal cardiac filling pressures. Eplerenone is indicated only for reduced ejection fraction heart failure or post-MI heart failure with LVEF ≤40%. The TOPCAT trial showed only marginal benefit in symptomatic HFpEF requiring hospitalization, which does not apply to me. A 2016 RCT showed no vascular benefit from eplerenone in patients with preserved EF and coronary disease. My mild edema is venous, not cardiac. Continuing eplerenone exposes me to hyperkalemia risk without evidence-based benefit." 1, 5, 2

Common Pitfalls to Avoid

• Do not confuse diastolic dysfunction with heart failure. Grade 1 diastolic dysfunction is extremely common in adults over 65 and does not warrant heart failure medications in the absence of symptoms or elevated filling pressures. 4
• Do not treat echocardiographic findings in isolation. Mild concentric LV hypertrophy requires blood pressure control, not aldosterone antagonists. 4
• Recognize that eplerenone's proven benefits are confined to specific populations (post-MI HFrEF with LVEF ≤30-40%), and extrapolation to preserved EF is not supported by evidence. 2, 3