Effectiveness and safety of aldosterone antagonist therapy use among older patients with reduced ejection fraction after acute myocardial infarction

Tracy Y. Wang, Amit N. Vora, S. Andrew Peng, Gregg C. Fonarow, Sandeep R Das, James A de Lemos, Eric D. Peterson

Research output: Contribution to journalArticle

4 Citations (Scopus)

Abstract

Background-While aldosterone antagonists have proven benefit among post-myocardial infarction (MI) patients with low ejection fraction (EF), how this treatment is used among older MI patients in routine practice is not well described. Methods and Results-Using ACTION Registry-GWTG linked to Medicare data, we examined 12 080 MI patients ≥65 years with EF ≤40% who were indicated for aldosterone antagonist therapy per current guidelines and without documented contraindications. Of these, 11% (n=1310) were prescribed aldosterone antagonists at discharge. Notably, 10% of patients prescribed an aldosterone antagonist were eligible for, but not concurrently treated with, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Spironolactone was the predominantly prescribed aldosterone antagonist. At 2-year follow-up, aldosterone antagonist use was not associated with lower mortality (unadjusted 39% versus 38%; HR 0.99, 95% CI 0.88-1.33 using inverse probabilityweighted propensity adjustment) except in symptomatic HF patients (HR 0.84, 95% CI 0.72-0.99, Pinteraction=0.009). Risks of hyperkalemia were low at 30 days, but significantly higher among patients prescribed aldosterone antagonists (unadjusted 2.3% versus 1.5%; adjusted HR 2.04, 95% CI 1.16-3.60), as was 2-year risk of acute renal failure (unadjusted 6.7% versus 4.8%; adjusted HR 1.39, 95% CI 1.01-1.92) compared with patients not prescribed aldosterone antagonists. Conclusions-Aldosterone antagonist use among eligible older MI patients in routine clinical practice was not associated with lower mortality except in patients with HF symptoms, but was associated with increased risks of hyperkalemia and acute renal failure. These results underscore the importance of close post-discharge monitoring of this patient population.

Original languageEnglish (US)
Article numbere002612
JournalJournal of the American Heart Association
Volume5
Issue number1
DOIs
StatePublished - 2016

Fingerprint

Mineralocorticoid Receptor Antagonists
Myocardial Infarction
Safety
Hyperkalemia
Therapeutics
Acute Kidney Injury
Spironolactone
Mortality
Patient Discharge
Angiotensin Receptor Antagonists
Physiologic Monitoring
Medicare
Angiotensin-Converting Enzyme Inhibitors
Registries
Guidelines

Keywords

  • Aldosterone antagonist therapy
  • Heart failure
  • Mortality
  • Older population

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Effectiveness and safety of aldosterone antagonist therapy use among older patients with reduced ejection fraction after acute myocardial infarction. / Wang, Tracy Y.; Vora, Amit N.; Peng, S. Andrew; Fonarow, Gregg C.; Das, Sandeep R; de Lemos, James A; Peterson, Eric D.

In: Journal of the American Heart Association, Vol. 5, No. 1, e002612, 2016.

Research output: Contribution to journalArticle

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title = "Effectiveness and safety of aldosterone antagonist therapy use among older patients with reduced ejection fraction after acute myocardial infarction",
abstract = "Background-While aldosterone antagonists have proven benefit among post-myocardial infarction (MI) patients with low ejection fraction (EF), how this treatment is used among older MI patients in routine practice is not well described. Methods and Results-Using ACTION Registry-GWTG linked to Medicare data, we examined 12 080 MI patients ≥65 years with EF ≤40{\%} who were indicated for aldosterone antagonist therapy per current guidelines and without documented contraindications. Of these, 11{\%} (n=1310) were prescribed aldosterone antagonists at discharge. Notably, 10{\%} of patients prescribed an aldosterone antagonist were eligible for, but not concurrently treated with, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Spironolactone was the predominantly prescribed aldosterone antagonist. At 2-year follow-up, aldosterone antagonist use was not associated with lower mortality (unadjusted 39{\%} versus 38{\%}; HR 0.99, 95{\%} CI 0.88-1.33 using inverse probabilityweighted propensity adjustment) except in symptomatic HF patients (HR 0.84, 95{\%} CI 0.72-0.99, Pinteraction=0.009). Risks of hyperkalemia were low at 30 days, but significantly higher among patients prescribed aldosterone antagonists (unadjusted 2.3{\%} versus 1.5{\%}; adjusted HR 2.04, 95{\%} CI 1.16-3.60), as was 2-year risk of acute renal failure (unadjusted 6.7{\%} versus 4.8{\%}; adjusted HR 1.39, 95{\%} CI 1.01-1.92) compared with patients not prescribed aldosterone antagonists. Conclusions-Aldosterone antagonist use among eligible older MI patients in routine clinical practice was not associated with lower mortality except in patients with HF symptoms, but was associated with increased risks of hyperkalemia and acute renal failure. These results underscore the importance of close post-discharge monitoring of this patient population.",
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AU - Wang, Tracy Y.

AU - Vora, Amit N.

AU - Peng, S. Andrew

AU - Fonarow, Gregg C.

AU - Das, Sandeep R

AU - de Lemos, James A

AU - Peterson, Eric D.

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N2 - Background-While aldosterone antagonists have proven benefit among post-myocardial infarction (MI) patients with low ejection fraction (EF), how this treatment is used among older MI patients in routine practice is not well described. Methods and Results-Using ACTION Registry-GWTG linked to Medicare data, we examined 12 080 MI patients ≥65 years with EF ≤40% who were indicated for aldosterone antagonist therapy per current guidelines and without documented contraindications. Of these, 11% (n=1310) were prescribed aldosterone antagonists at discharge. Notably, 10% of patients prescribed an aldosterone antagonist were eligible for, but not concurrently treated with, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Spironolactone was the predominantly prescribed aldosterone antagonist. At 2-year follow-up, aldosterone antagonist use was not associated with lower mortality (unadjusted 39% versus 38%; HR 0.99, 95% CI 0.88-1.33 using inverse probabilityweighted propensity adjustment) except in symptomatic HF patients (HR 0.84, 95% CI 0.72-0.99, Pinteraction=0.009). Risks of hyperkalemia were low at 30 days, but significantly higher among patients prescribed aldosterone antagonists (unadjusted 2.3% versus 1.5%; adjusted HR 2.04, 95% CI 1.16-3.60), as was 2-year risk of acute renal failure (unadjusted 6.7% versus 4.8%; adjusted HR 1.39, 95% CI 1.01-1.92) compared with patients not prescribed aldosterone antagonists. Conclusions-Aldosterone antagonist use among eligible older MI patients in routine clinical practice was not associated with lower mortality except in patients with HF symptoms, but was associated with increased risks of hyperkalemia and acute renal failure. These results underscore the importance of close post-discharge monitoring of this patient population.

AB - Background-While aldosterone antagonists have proven benefit among post-myocardial infarction (MI) patients with low ejection fraction (EF), how this treatment is used among older MI patients in routine practice is not well described. Methods and Results-Using ACTION Registry-GWTG linked to Medicare data, we examined 12 080 MI patients ≥65 years with EF ≤40% who were indicated for aldosterone antagonist therapy per current guidelines and without documented contraindications. Of these, 11% (n=1310) were prescribed aldosterone antagonists at discharge. Notably, 10% of patients prescribed an aldosterone antagonist were eligible for, but not concurrently treated with, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. Spironolactone was the predominantly prescribed aldosterone antagonist. At 2-year follow-up, aldosterone antagonist use was not associated with lower mortality (unadjusted 39% versus 38%; HR 0.99, 95% CI 0.88-1.33 using inverse probabilityweighted propensity adjustment) except in symptomatic HF patients (HR 0.84, 95% CI 0.72-0.99, Pinteraction=0.009). Risks of hyperkalemia were low at 30 days, but significantly higher among patients prescribed aldosterone antagonists (unadjusted 2.3% versus 1.5%; adjusted HR 2.04, 95% CI 1.16-3.60), as was 2-year risk of acute renal failure (unadjusted 6.7% versus 4.8%; adjusted HR 1.39, 95% CI 1.01-1.92) compared with patients not prescribed aldosterone antagonists. Conclusions-Aldosterone antagonist use among eligible older MI patients in routine clinical practice was not associated with lower mortality except in patients with HF symptoms, but was associated with increased risks of hyperkalemia and acute renal failure. These results underscore the importance of close post-discharge monitoring of this patient population.

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KW - Heart failure

KW - Mortality

KW - Older population

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