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Clinical question: Are aldosterone antagonists appropriately used in heart failure patients?

Background: Aldosterone antagonists are Class 1 treatment for patients with heart failure (HF) and low left ventricular ejection fraction (LVEF), according to the latest American College of Cardiology/American Heart Association (ACC/AHA) Chronic HF Guidelines. However, acceptance of the guidelines has been slow, possibly because of contraindications and adverse effects in some patients.

Study design: Observational cohort.

Setting: Inpatients at 241 hospitals participating in an HF registry.

Synopsis: Eligible inpatients from a QI registry who were discharged home from January 2005 to December 2007 were analyzed for appropriate and inappropriate aldosterone antagonist use.

Among the 12,565 patients who met the criteria for aldosterone antagonist therapy, only 4,087 (32.5%) received the therapy at discharge. In contrast, of the 8,610 total patients with HF discharged on aldosterone antagonists, 269 (3.1%) met at least one criterion for inappropriate use, and 640 (7.4%) met at least one criteria for potentially inappropriate use.

Use of an aldosterone antagonist was more likely in certain patient groups, including those who were younger, African-American, had lower systolic blood pressure, had no history of renal insufficiency, and those with implantable cardioverter-defibrillators. The authors noted aldosterone use increased significantly during the study period.

The study was limited by the possibility that aldosterone antagonists were used for non-HF conditions and the fact that it was retrospective.

Bottom line: Aldosterone antagonists are used in less than one-third of eligible HF patients.

Citation: Albert NM, Yancy CW, Liang L, et al. Use of aldosterone antagonists in heart failure. JAMA. 2009;302(15):1658-1665.

Reviewed for TH eWire by Jill Goldenberg, MD, Alan Briones, MD, Dennis Chang, MD, Brian Markoff, MD, FHM, Erin Rule, MD, Andrew Dunn, MD, FACP, FHM, Division of General Internal Medicine, Mount Sinai School of Medicine, New York City

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