Gianluigi Savarese1, Juan-Jesus Carrero2, Bertram Pitt3, Stefan D Anker4,5, Giuseppe M C Rosano6,7, Ulf Dahlström8, Lars H Lund1,9. 1. Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden. 2. Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. 3. Department of Medicine, University of Michigan, Ann Arbor, MI, USA. 4. Division of Cardiology and Metabolism, Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Germany. 5. Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Göttingen, Germany. 6. Cardiovascular and Cell Sciences Research Institute, St George's University, London, UK. 7. IRCCS San Raffaele Pisana, Rome, Italy. 8. Department of Cardiology and Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden. 9. Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.
Abstract
AIM: Mineralocorticoid receptor antagonists (MRAs) improve outcomes in heart failure with reduced ejection fraction (HFrEF), but are underutilized. Hyperkalaemia may be one reason, but the underlying reasons for underuse are unknown. The aim of this study was to investigate the independent predictors of MRA underuse in a large and unselected HFrEF cohort. METHODS AND RESULTS: We included patients with HFrEF (ejection fraction <40%), New York Heart Association (NYHA) class II-IV and heart failure (HF) duration ≥6 months from the Swedish HF Registry. Logistic regression analysis identified independent associations between 39 demographic, clinical, co-treatment, and socioeconomic predictors and MRA non-use. Of 11 215 patients, 27% were women; mean age was 75 ± 11 years; only 4443 (40%) patients received MRA. Selected characteristics independently associated with MRA non-use were in descending order of magnitude: lower creatinine clearance (<60 mL/min), no need for diuretics, no cardiac resynchronization therapy/implantable cardioverter-defibrillator, higher blood pressure, no digoxin use, higher ejection fraction, outpatient setting, older age, lower income, ischaemic heart disease, male sex, follow-up in primary vs. specialty care, lower NYHA class, and absence of hypertension diagnosis. Plasma potassium and N-terminal pro B-type natriuretic peptide levels were not associated with MRA non-use. CONCLUSION: Mineralocorticoid receptor antagonists remain underused in HFrEF. Their use does not decrease with elevated potassium but does with impaired renal function, even in the creatinine clearance 30-59.9 mL/min range where MRAs are not contraindicated. MRA underuse may be further related to non-specialist care, milder HF and no use of other HF therapy.
AIM: Mineralocorticoid receptor antagonists (MRAs) improve outcomes in heart failure with reduced ejection fraction (HFrEF), but are underutilized. Hyperkalaemia may be one reason, but the underlying reasons for underuse are unknown. The aim of this study was to investigate the independent predictors of MRA underuse in a large and unselected HFrEF cohort. METHODS AND RESULTS: We included patients with HFrEF (ejection fraction <40%), New York Heart Association (NYHA) class II-IV and heart failure (HF) duration ≥6 months from the Swedish HF Registry. Logistic regression analysis identified independent associations between 39 demographic, clinical, co-treatment, and socioeconomic predictors and MRA non-use. Of 11 215 patients, 27% were women; mean age was 75 ± 11 years; only 4443 (40%) patients received MRA. Selected characteristics independently associated with MRA non-use were in descending order of magnitude: lower creatinine clearance (<60 mL/min), no need for diuretics, no cardiac resynchronization therapy/implantable cardioverter-defibrillator, higher blood pressure, no digoxin use, higher ejection fraction, outpatient setting, older age, lower income, ischaemic heart disease, male sex, follow-up in primary vs. specialty care, lower NYHA class, and absence of hypertension diagnosis. Plasma potassium and N-terminal pro B-type natriuretic peptide levels were not associated with MRA non-use. CONCLUSION:Mineralocorticoid receptor antagonists remain underused in HFrEF. Their use does not decrease with elevated potassium but does with impaired renal function, even in the creatinine clearance 30-59.9 mL/min range where MRAs are not contraindicated. MRA underuse may be further related to non-specialist care, milder HF and no use of other HF therapy.
Authors: Stephen J Greene; G Michael Felker; Anna Giczewska; Andreas P Kalogeropoulos; Andrew P Ambrosy; Hrishikesh Chakraborty; Adam D DeVore; Marat Fudim; Steven E McNulty; Robert J Mentz; Muthiah Vaduganathan; Adrian F Hernandez; Javed Butler Journal: Can J Cardiol Date: 2019-02-07 Impact factor: 5.223
Authors: Willemien J Kruik-Kollöffel; Gerard C M Linssen; H Joost Kruik; Kris L L Movig; Edith M Heintjes; Job van der Palen Journal: Heart Fail Rev Date: 2019-07 Impact factor: 4.214
Authors: Essraa Bayoumi; Phillip H Lam; Daniel J Dooley; Steven Singh; Charles Faselis; Charity J Morgan; Samir Patel; Helen M Sheriff; Selma F Mohammed; Carlos E Palant; Bertram Pitt; Gregg C Fonarow; Ali Ahmed Journal: Am J Med Date: 2018-09-19 Impact factor: 4.965
Authors: Henry Han; Grace Chung; Emily Sippola; Wilson Chen; Spencer Morgan; Elizabeth Renner; Allison Ruff; Anne Sales; Jacob Kurlander; Geoffrey D Barnes Journal: Res Pract Thromb Haemost Date: 2021-07-16