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Evolving role for mineralocorticoid receptor antagonists in heart failure with preserved ejection fraction

Miller, Robert J.H.; Howlett, Jonathan G.

Current Opinion in Cardiology: March 2015 - Volume 30 - Issue 2 - p 168–172
doi: 10.1097/HCO.0000000000000147
HEART FAILURE: Edited by Haissam Haddad

Purpose of review The majority of randomized clinical trials in heart failure with preserved ejection fraction (HFpEF) have failed to show meaningful improvements in clinical outcomes. Recent randomized trials have shown benefits from mineralocorticoid receptor antagonists (MRAs) in the management of HFpEF. This review will focus on new evidence for MRA therapy in patients with HFpEF.

Recent findings Three randomized trials were reviewed: the Effect of spironolactone on diastolic function and exercise capacity in patients with heart failure with preserved ejection fraction: the Aldo-DHF randomized controlled trial; the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial; and its echocardiography substudy. The Aldo-DHF trial showed improvements in echocardiographic measures of diastolic function. In the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist trial, hospitalization for heart failure was significantly reduced with MRA therapy with no difference in the primary outcome of cardiovascular death or hospitalization. In patients with high risk, however, there may be a reduction in cardiovascular mortality. We will also briefly discuss finerenone, a new generation MRA associated with a lower incidence of hyperkalemia.

Summary New evidence shows that MRA therapy decreases left ventricular mass and left atrial size, reduces hospitalization, and may reduce cardiovascular mortality in patients with high risk.

Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada

Correspondence to Jonathan G. Howlett, MD, FRCPC, FACC, Room C-838, 1403 – 29th Street NW, Calgary, AB T2N 2Y8, Canada. Tel: +1 403 944 3232; fax: +1 403 944 3262; e-mail:

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