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) 1. Eplerenone is a mineralocorticoid receptor antagonist (MRA) that has demonstrated mortality benefit in patients with HFrEF in large clinical trials 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 good candidate for this medication.
When considering the management of heart failure in patients with chronic coronary syndromes, the 2024 ESC guidelines recommend the use of an MRA, such as eplerenone, in patients with HFrEF to reduce the risk of HF hospitalization and death 1. The guidelines also recommend the use of an ACE-I, an SGLT2 inhibitor, and a beta-blocker in these patients 1.
Key points to consider when adding eplerenone to this patient's regimen include:
- Monitoring potassium levels regularly, especially in the first few weeks of therapy, as hyperkalemia is a potential side effect
- Starting with a typical dose of 25 mg daily, which can be titrated up to 50 mg daily if tolerated
- Considering the patient's current medication regimen and potential interactions with eplerenone
None of the other options (increasing Lasix, adding amlodipine, adding digoxin, or adding ivabradine/Corlanor) have shown the same consistent mortality benefit in patients with HFrEF as adding an MRA like eplerenone 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.
- The EPHESUS study 2 demonstrated a 15% reduction in the risk of death from any cause with eplerenone compared to placebo in patients with heart failure post-myocardial infarction.
- The patient in question has a history of MI, chronic hypertension, and a left ventricular ejection fraction of 32%, which is similar to the patient population in the EPHESUS study.
- Eplerenone has been shown to be effective in reducing mortality in patients with heart failure post-MI, making it a suitable option for this patient.
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: aspirin 81, atorvastatin 40, Lasix 40, Lepri 20, Toprol XL 100
- Echocardiogram shows left ventricular ejection fraction (LVEF) of 32%
- Patient reports difficulty walking up a single flight of stairs
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
- Mineralocorticoid receptor antagonists (MRAs) have also been shown to be effective in reducing mortality and morbidity in patients with HFrEF, particularly in those with higher body weight 6
- There is no direct evidence to support the use of digoxin, Corlanor, or increasing Lasix dose in this patient population
- Medication adherence is crucial in ensuring the effectiveness of treatment, and healthcare professionals play an important role in promoting adherence 7
Potential Benefits of ARNI Therapy
- Reduced mortality and hospitalization
- Improved quality of life
- Decreased NT-proBNP levels
- Reduced length of hospital stay
Potential Benefits of MRA Therapy
- Reduced mortality and morbidity
- Improved outcomes in patients with higher body weight
- Reduced risk of heart failure hospitalization and cardiovascular death