From the Guidelines
Spironolactone is not primarily used for coronary artery disease (CAD), but it may be beneficial in patients with heart failure who also have CAD, as evidenced by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
Key Points to Consider
- Spironolactone is a potassium-sparing diuretic and aldosterone antagonist that is mainly used to treat conditions like heart failure, primary hyperaldosteronism, edema, and resistant hypertension.
- The standard medications for CAD typically include antiplatelet agents (like aspirin), statins to lower cholesterol, beta-blockers, ACE inhibitors or ARBs, and nitrates for symptom relief.
- Spironolactone works by blocking aldosterone receptors, which helps reduce fluid retention and blood pressure, but does not directly address the atherosclerotic process that causes CAD.
- According to the 2022 AHA/ACC/HFSA guideline, spironolactone reduced the risk of the primary composite endpoint of cardiovascular death, HF hospitalization, or resuscitated sudden death in a subgroup of patients with LVEF 44% to 49% 1.
Treatment Approach
- If you have CAD, your treatment should be guided by a cardiologist who will prescribe appropriate medications based on your specific condition and symptoms.
- The treatment of hypertension in patients with HF should include behavioral modification, such as sodium restriction, and a closely monitored exercise program, as well as medications like diuretics, ACE inhibitors (or ARBs), β-blockers, and aldosterone receptor antagonists 1.
- The target BP is <130/80 mm Hg, but consideration should be given to lowering the BP even further, to <120/80 mm Hg, especially in patients with an elevated DBP who have CAD and HF with evidence of myocardial ischemia 1.
From the Research
Spironolactone in CAD
- Spironolactone is used in patients with coronary artery disease (CAD) to reduce the incidence of arrhythmias and improve cardiac function 2.
- The medication has been shown to decrease ventricular extrasystoles, QT interval length, and collagen markers in patients with CAD without heart failure 2.
- The possible mechanisms of spironolactone in CAD patients include promoting myocardial fibrosis, lengthening the QTc interval, and decreasing potassium levels 2.
Spironolactone in Heart Failure
- Spironolactone is used to treat heart failure with reduced ejection fraction and has been shown to reduce morbidity and mortality in these patients 3, 4, 5.
- The medication has also been used to treat heart failure with preserved ejection fraction, particularly in patients with resistant hypertension 6.
- Spironolactone has been shown to improve outcomes in patients with heart failure with preserved ejection fraction and resistant hypertension, including reducing the risk of cardiovascular death, aborted cardiac arrest, or heart failure hospitalization 6.
Safety and Tolerability
- Spironolactone has been shown to be safe and tolerable in patients with heart failure and chronic kidney disease, although patients with CKD stage 3 may have a higher risk of inpatient hyperkalemia 3.
- The medication has been associated with an increased risk of hyperkalemia, but not with acute kidney injury 5.
- Spironolactone should be used with caution in patients with renal impairment and those at risk of hyperkalemia 3, 5.