Look for Heart Failure Patients Who May Need an Aldosterone Antagonist

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 HF with reduced ejection fraction (HFrEF) or "hef-ref."

Think of an ACEI or ARB, beta-blocker, and aldosterone antagonist combo 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...metoprolol succinate, carvedilol, or bisoprolol. Advise titrating both classes to target doses as tolerated.

Then in most cases, suggest adding an aldosterone antagonist if patients still have symptoms...even milder ones, such as fatigue or slight shortness of breath with usual activity.

Lean toward spironolactone...it costs about $5/month vs $90/month for eplerenone. But 10% of men on spironolactone 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 meds and foods that can raise potassium... trimethoprim, TMP/SMX, salt substitutes, potatoes, 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 costs $430/month.

Listen to PL Voices to hear us discuss the role of aldosterone antagonists. Use our toolbox, Improving Heart Failure Care, to optimize meds, improve adherence, and help manage "diastolic" heart failure.

Key References

  • Circulation 2017;136(6):e137-e161
  • J Am Heart Assoc 2016;5(3):e002493
  • J Am Heart Assoc 2015;4(12);e002268
  • J Am Coll Cardiol 2017;70(16):2048-90
  • Medication pricing by Elsevier, accessed Nov 2017
Pharmacist's Letter. Dec 2017, No. 331202

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