Aldosterone-receptor antagonists in heart failure: insights after EMPHASIS-HF

The recent publication of the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) has affirmed the important role of aldosterone-receptor antagonism across the spectrum of systolic heart failure. Previously restricted as therapy in patients with severe symptomatic or postinfarction heart failure, it now is being considered in less-sick patients. The precise mechanisms of benefit remain to be elucidated, in part due to the observed discrepancy between improved outcomes and the lack of reverse cardiac remodeling with aldosterone-receptor antagonists. With the probable increased use of spironolactone and eplerenone, there are concerns for increased complications, especially hyperkalemia. This risk must be balanced against the potential benefit for reduced mortality and morbidity in addition to effects of β-blockers and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and cardiac resynchronization therapy.