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Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction

Eric C Wong1, Christopher B Fordyce2,3,4, Graham Wong2,4

  • 1Division of General Internal Medicine Department of Medicine University of British Columbia Vancouver British Columbia Canada.

Journal of the American Heart Association
|July 6, 2021
PubMed

Insights

Mineralocorticoid receptor antagonists (MRAs) are recommended for eligible heart attack patients, but real-world use remains low. Only 22% received MRAs at discharge, highlighting a gap in post-heart attack care and the need for better decision support.

Area of Science:

  • Cardiology
  • Pharmacotherapy
  • Outcomes Research

Background:

  • Mineralocorticoid receptor antagonists (MRAs) are guideline-recommended post-myocardial infarction (MI) for patients with heart failure or diabetes mellitus.
  • Efficacy and survival benefits are established in trials like EPHESUS, particularly for those with reduced left ventricular ejection fraction (LVEF).

Purpose of the Study:

  • To assess the real-world utilization of MRAs in patients who experienced ST-segment-elevation myocardial infarction (STEMI) and developed left ventricular dysfunction.
  • To identify factors influencing MRA prescription rates in this high-risk population.

Main Methods:

  • A prospective, population-based study linked STEMI registry data with cardiology outpatient records (2007-2018).
  • Eligibility for MRAs was defined using EPHESUS criteria: LVEF ≤40% plus clinical heart failure or diabetes mellitus, excluding dialysis-dependent renal dysfunction.
  • Primary outcome: MRA prescription at discharge; Secondary outcome: MRA prescription within 3 months post-discharge.

Main Results:

  • Of 2691 STEMI patients, 317 (12%) met MRA eligibility criteria.
  • Only 70 (22%) eligible patients received an MRA at discharge.
  • Among those not prescribed an MRA at discharge, 9.5% received one within 3 months.
  • Lower LVEF and later calendar year were associated with increased MRA prescription at discharge.

Conclusions:

  • Real-world MRA uptake in eligible STEMI patients remains suboptimal, with only about one-quarter prescribed within 3 months post-hospitalization.
  • Significant gaps exist in guideline-directed medical therapy for post-STEMI care.
  • Development of decision-support tools is crucial to improve MRA prescribing and address this care gap.

Keywords:
acute coronary syndromealdosterone antagonistheart failure

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