From the Guidelines
The correct intervention to improve survival in this patient 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 been shown in multiple clinical trials to reduce mortality in patients with HFrEF, as supported by the 2013 ACCF/AHA guideline for the management of heart failure 1 and the 2015 treatment of hypertension in patients with coronary artery disease guideline 1. The medication works by blocking aldosterone receptors, which helps reduce sodium and water retention, myocardial fibrosis, and sympathetic activation. The typical starting dose would be 25 mg daily, with monitoring of potassium and renal function. While the patient is already on several appropriate medications for her condition (including an ACE inhibitor, beta-blocker, diuretic, and statin), the addition of an MRA like eplerenone represents guideline-directed medical therapy that would provide additional mortality benefit, as also recommended by the 2020 guideline-directed medical therapy for heart failure guideline 1 and the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. The other options would not provide the same mortality benefit - increasing Lasix would only address symptoms, amlodipine could worsen heart failure, digoxin may improve symptoms but doesn't reduce mortality, and ivabradine (Corlanor) is primarily used for heart rate control in patients who remain symptomatic despite optimal therapy. Some key points to consider when adding eplerenone include:
- Monitoring of potassium and renal function
- Starting dose of 25 mg daily
- Contraindications such as hyperkalemia or severe renal impairment
- Potential interactions with other medications, such as ACE inhibitors or ARBs. Overall, the addition of eplerenone to this patient's medication regimen is a crucial step in optimizing her treatment and improving her survival, as supported by the most recent and highest quality studies 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. This is based on the results of the EPHESUS study, which demonstrated a 15% reduction in the risk of death from any cause in patients with heart failure post-myocardial infarction who received eplerenone compared to those who received placebo 2, 2, 2.
- Key points:
- Eplerenone reduced the risk of death from any cause by 15% in the EPHESUS study.
- The study population had heart failure post-myocardial infarction with left ventricular ejection fraction ≤40%.
- Eplerenone is indicated to improve survival of stable patients with symptomatic heart failure with reduced ejection fraction (≤40%) after an acute myocardial infarction (MI).
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
- Echocardiogram shows a left ventricular ejection fraction of 32%
- Patient reports difficulty walking up a single flight of stairs
Treatment Options
- The patient's condition is consistent with heart failure with reduced ejection fraction (HFrEF)
- According to the studies, the following interventions have been shown to improve survival in patients with HFrEF:
- Adding a mineralocorticoid receptor antagonist, such as eplerenone 3
- Using diuretics to relieve symptoms, and applying disease-modifying drug and device therapies 4
- Inhibition of the renin-angiotensin-aldosterone and sympathetic nervous systems improves survival and decreases hospitalizations in patients with HFrEF 5
- Ensuring goal-directed management and therapy within 6 months of diagnosis to reduce morbidity and mortality 6
- Specifically, option D, adding eplerenone, has been shown to improve survival in patients with HFrEF, as demonstrated in the EMPHASIS-HF trial 3
Relevant Studies
- The EMPHASIS-HF trial showed that eplerenone reduces the risk of cardiovascular death or first hospitalization for heart failure in patients with HFrEF 3
- A review of HFrEF management highlights the importance of diuretics, beta blockers, and mineralocorticoid receptor antagonists in improving survival and reducing hospitalizations 4
- A practical guide for the treatment of symptomatic HFrEF outlines the management of patients with systolic heart failure, including the use of diuretics, beta blockers, and aldosterone antagonists 5
- A review of heart failure with reduced ejection fraction emphasizes the importance of goal-directed management and therapy to reduce morbidity and mortality 6
- A review of the management of HFrEF in patients with atrial fibrillation, renal disease, and in the elderly highlights the challenges and complexities of treating these patients 7