Heart failure patients who may need an aldosterone antagonist

In most cases, suggest adding an aldosterone antagonist (spironolactone, eplerenone) if patients still have symptoms....

Less than half of eligible heart failure patients take an aldosterone antagonist (spironolactone, eplerenone). Help close the gap for patients with systolic heart failure. Now called heart failure with reduced ejection fraction (HFrEF). Think of an angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), beta-blocker (BB), and aldosterone antagonist combination as a "3-legged stool" to reduce mortality in these patients.

Continue to recommend starting with an ACEI or ARB plus an "evidence-based" beta-blocker like metoprolol (Seloken Zoc), carvedilol (Dilatrend), or bisoprolol (Concor). Advise titrating both classes to target doses as tolerated. Then in most cases, suggest adding an aldosterone antagonist (spironolactone, eplerenone) if patients still have symptoms, even milder ones, such as fatigue or slight shortness of breath with usual activity. Lean toward spironolactone, it is NOT expensive vs eplerenone. But 10% of men on spironolactone (Aldactone) develop gynecomastia.

Help minimize hyperkalemia. Suggest starting low and going slow when adding an aldosterone antagonist. For spironolactone, usually advise starting with 12.5 mg daily and titrating to 25 mg daily after 4 weeks. Pushing to 50 mg/day may cause more hyperkalemia and usually isn't needed. Confirm patients can get frequent labs if an aldosterone antagonist is added to an ACEI or ARB. Advise checking potassium and renal function at 3 to 7 days, one month, and then about every 3 months after starting. Also suggest monitoring after doses of the ACEI, ARB, or aldosterone antagonist are increased or diuretic doses are adjusted. Warn patients to avoid NSAIDs, they can worsen heart failure symptoms and renal function. Caution about other medications and foods that can raise potassium like trimethoprim, TMP/SMX, salt substitutes, potatoes, bananas, etc. And 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). Using Entresto instead of an ACEI improves outcomes, but causes more hypotension and it is very expensive. See additional note Overview of heart failure treatment.

References

Yancy, C.W., Jessup, and others. 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, 136(6). Available at: https://pubmed.ncbi.nlm.nih.gov/28455343

Dev, S., Hoffman, and others (2016). Barriers to Adoption of Mineralocorticoid Receptor Antagonists in Patients with Heart Failure: A Mixed-Methods Study. Journal of the American Heart Association, [online] 5(3), p.e002493. Available at: https://pubmed.ncbi.nlm.nih.gov/27032719

Dev, S., Lacy, M.E., Masoudi, F.A. and Wu, W.-C. (2015). Temporal Trends and Hospital Variation in Mineralocorticoid Receptor Antagonist Use in Veterans Discharged With Heart Failure. Journal of the American Heart Association, [online] 4(12). Available at: https://pubmed.ncbi.nlm.nih.gov/26702082