From the Guidelines
The intervention that has been shown to improve survival in patients like this is option D, adding eplerenone. This 69-year-old female has heart failure with reduced ejection fraction (HFrEF) as evidenced by her left ventricular ejection fraction of 32% and symptoms of exertional dyspnea (difficulty walking up stairs). Eplerenone is a mineralocorticoid receptor antagonist (MRA) that has demonstrated mortality benefit in patients with HFrEF in large clinical trials, as shown in the RALES study 1 and further supported by the EPHESUS study 1. It works by blocking aldosterone, which reduces sodium retention, decreases fibrosis, and improves cardiac remodeling. The patient's kidney function is normal, making her a suitable candidate for this medication.
When starting eplerenone, it's essential to monitor potassium levels regularly, especially in the first few weeks of therapy, as hyperkalemia is a potential side effect. The typical starting dose is 25 mg daily, which can be titrated up to 50 mg daily if tolerated. The 2024 ESC guidelines for the management of chronic coronary syndromes also recommend the use of an MRA, such as eplerenone, in patients with HFrEF to reduce the risk of HF hospitalization and death 1.
The other options (increasing Lasix, adding amlodipine, adding digoxin, or adding ivabradine/Corlanor) have not shown the same consistent mortality benefit in patients with HFrEF as mineralocorticoid receptor antagonists like eplerenone. Therefore, adding eplerenone is the most appropriate intervention to improve survival in this patient, given the current evidence and guidelines. Key considerations in managing this patient include:
- Monitoring renal function and potassium levels closely after initiating eplerenone
- Optimizing other medications according to current guidelines for HFrEF
- Considering enrollment in a multidisciplinary HF management programme to reduce the risk of HF hospitalization and improve survival, as recommended by the 2024 ESC guidelines 1.
From the FDA Drug Label
The eplerenone post-acute myocardial infarction heart failure efficacy and survival study (EPHESUS) was a multinational, multicenter, double-blind, randomized, placebo-controlled study in patients clinically stable 3 to 14 days after an acute MI with LV dysfunction (as measured by left ventricular ejection fraction [LVEF] ≤40%) and either diabetes or clinical evidence of HF (pulmonary congestion by exam or chest x-ray or S 3). For the co-primary endpoint for death from any cause, there were 478 deaths in the eplerenone group (14.4%) and 554 deaths in the placebo group (16.7%). The risk of death with eplerenone was reduced by 15% [hazard ratio equal to 0.85 (95% confidence interval 0.75 to 0.96; p = 0. 008 by log rank test)].
The intervention that has been shown to improve survival in patients such as the one described is:
- Adding Eplerenone (option D), as evidenced by the EPHESUS study, which demonstrated a 15% reduction in the risk of death from any cause in patients with left ventricular dysfunction after an acute myocardial infarction 2.
From the Research
Patient Profile
- 69-year-old female with a history of chronic hypertension and previous MI
- Hospitalized for chest pain six weeks prior, with authorization showing one lesion in the circumflex artery less than 50% occluded
- Current medications include aspirin, atorvastatin, Lasix, Lepri, and Toprol XL
- Patient reports difficulty walking up a single flight of stairs, despite feeling comfortable at rest
Current Condition
- Echocardiogram shows left ventricular ejection fraction of 32%
- EKG reveals sinus rhythm with multiple PVCs and a QRS interval of 0.1 seconds
- Blood pressure is 132/78, with a pulse of 55
- Exam shows regular rhythm, no murmur, soft S3 and S4, and bilateral crackles
Intervention Options
- Option A: Increase Lasix dose
- Option B: Add a lot of pain medication
- Option C: Add digoxin
- Option D: Add Eplerenone
- Option E: Add Corlanor
Evidence-Based Recommendations
- Studies have shown that angiotensin receptor-neprilysin inhibitors (ARNIs) can improve survival and reduce hospitalization in patients with heart failure with reduced ejection fraction (HFrEF) 3, 4, 5
- ARNIs have been found to be superior to traditional RAAS antagonizing agents in reducing heart failure hospitalization and mortality 4
- The use of ARNIs has also been shown to have renoprotective functions in heart failure patients, including those with chronic or end-stage kidney disease 6
- However, none of the provided options directly mention the use of ARNIs, and therefore, it is unclear which option would be the most effective in improving survival and reducing hospitalization in this patient.
- It is worth noting that increasing the dose of Lasix (Option A) may help with volume control, but it may also have adverse effects on renal function 6
- Adding Eplerenone (Option D) may be beneficial in patients with HFrEF, as it has been shown to reduce mortality and morbidity in these patients 3
- Adding Corlanor (Option E) may also be beneficial, as it has been shown to reduce hospitalization and mortality in patients with HFrEF 3