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Optimizing Heart Failure Management: Benefits of Aldosterone Antagonists in HFrEF

Optimize heart failure management with aldosterone antagonists, ACE inhibitors, ARBs, and beta-blockers in HFrEF.

Introduction

Less than half of eligible heart failure patients take an aldosterone antagonist like spironolactone or eplerenone. Close the gap for patients with systolic heart failure, now known as heart failure with reduced ejection fraction (HFrEF).

RxPharm-adv

The "3-Legged Stool" Approach to HFrEF Treatment

Starting ACEI, ARB, and Beta-Blockers

Think of the combination of angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), beta-blockers (BB), and aldosterone antagonists as a "3-legged stool" to reduce mortality in HFrEF patients.

Start with an ACEI or ARB plus an "evidence-based" beta-blocker like metoprolol (Seloken Zoc), carvedilol (Dilatrend), or bisoprolol (Concor). Titrate both classes to target doses as tolerated.

Adding an Aldosterone Antagonist "Spironolactone"

If symptoms persist, even mild ones like fatigue or slight shortness of breath, suggest adding an aldosterone antagonist such as spironolactone or eplerenone. Lean toward spironolactone due to its lower cost. Note that 10% of men on spironolactone (Aldactone) may develop gynecomastia. Monitor for this side effect and consider alternatives if necessary.

Help minimize hyperkalemia. Start low and go slow when adding an aldosterone antagonist. For spironolactone, start with 12.5 mg daily and titrate to 25 mg daily after 4 weeks.

  • Avoid pushing to 50 mg/day to reduce hyperkalemia risk.
  • Ensure patients can get frequent labs if an aldosterone antagonist is added to an ACEI or ARB.
  • Check potassium and renal function at 3 to 7 days, one month, and then about every 3 months after starting.
  • Also monitor after dose increases of the ACEI, ARB, or aldosterone antagonist or if diuretic doses are adjusted.
  • Advise patients to avoid NSAIDs, as they can worsen heart failure symptoms and renal function.
  • Caution about other medications and foods that can raise potassium levels, such as trimethoprim, TMP/SMX, salt substitutes, potatoes, bananas, etc. Recommend stopping or reducing scheduled potassium supplements.

Don't be surprised if an aldosterone antagonist is added to a beta-blocker and Entresto (sacubitril/valsartan). Entresto improves outcomes but may cause more hypotension and is very expensive.

RxPharm-adv

Take-home points

Heart failure patients often miss key treatments...

  1. Close the gap for heart failure patients by using aldosterone antagonists like spironolactone or eplerenone.
  2. Think of the combination of ACEI or ARB, beta-blockers, and aldosterone antagonists as a "3-legged stool" to reduce mortality in HFrEF patients.
  3. Start with an ACEI or ARB and an "evidence-based" beta-blocker like metoprolol, carvedilol, or bisoprolol.
  4. Add an aldosterone antagonist like spironolactone if symptoms persist, even mild ones.
  5. Minimize hyperkalemia by starting with a low dose of spironolactone and titrating slowly.
  6. Monitor potassium and renal function regularly when adding aldosterone antagonists to ACEI or ARB.

References

  1. Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation. 2017;136(6):e137-e161. doi:10.1161/CIR.0000000000000509
    2. Show more references

Keywords: Heart failure management, HFrEF, Aldosterone antagonists, Spironolactone, Eplerenone, ACE inhibitors, ARB, Beta-blockers, Hyperkalemia, Clinical pharmacy

Senior clinical pharmacist, "Pharmacy Practice Department, Tanta University Hospital, Egypt". Medical content writer.