1. JAMA Intern Med. 2018 Jul 1;178(7):913-920. doi: 10.1001/jamainternmed.2018.0850.

Aldosterone Antagonist Therapy and Mortality in Patients With ST-Segment
Elevation Myocardial Infarction Without Heart Failure: A Systematic Review and
Meta-analysis.

Dahal K(1), Hendrani A(1), Sharma SP(2), Singireddy S(1), Mina G(1), Reddy P(1), 
Dominic P(1), Modi K(1).

Author information: 
(1)Division of Cardiology, Department of Medicine, Louisiana State University
Health Sciences Center, Shreveport.
(2)Department of Medicine, LRGHealthcare, University of New England, Laconia, New
Hampshire.

Comment in
    JAMA Intern Med. 2018 Jul 1;178(7):920-921.

Importance: Treatment with aldosterone antagonists is recommended and has been
shown to have beneficial effects in patients with ST-segment elevation myocardial
infarction (STEMI) and left ventricular ejection fraction (LVEF) less than 40%.
However, the role of aldosterone antagonists in patients with ejection fraction
greater than 40% or without congestive heart failure is not well known.
Objectives: To perform a systematic review and meta-analysis using standard
techniques to determine the role of therapy with aldosterone antagonists in this 
patient population.
Data Sources: PubMed, Embase, CINAHL, and Cochrane Central databases were
searched and a manual search for relevant references from the selected articles
and published reviews was performed from database inception through June 2017.
Study Selection: Randomized clinical trials that evaluated treatment with
aldosterone antagonists in patients with STEMI without clinical heart failure or 
LVEF greater than 40% were included.
Data Extraction and Synthesis: Preferred Reporting Items for Systematic Reviews
and Meta-analyses guidelines were used to conduct and report the meta-analysis,
which used a random-effects model. Two investigators independently performed the 
database search and agreed on the final study selection. A manual search was
performed for relevant references from the selected articles and published
reviews.
Main Outcomes and Measures: The outcomes analyzed were mortality, new congestive 
heart failure, recurrent myocardial infarction, ventricular arrhythmia, and
changes in LVEF, serum potassium level, and creatinine level at follow-up.
Results: In all, 10 randomized clinical trials with a total of 4147 unique
patients were included in the meta-analysis. In patients who presented with STEMI
without heart failure, treatment with aldosterone antagonists compared with
control was associated with lower risk of mortality (2.4% vs 3.9%; odds ratio
[OR], 0.62; 95% CI, 0.42-0.91; P = .01) and similar risks of myocardial
infarction (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; P = .91), new congestive
heart failure (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; P = .31), and
ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; P = .33).
Similarly, treatment with aldosterone antagonists compared with control was
associated with a small yet significant increase in LVEF (mean difference, 1.58%;
95% CI, 0.18%-2.97%; P = .03), a small increase in serum potassium level (mean
difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; P = .02), and no change in serum
creatinine level (standardized mean difference, 1.4; 95% CI, -0.43 to 3.24;
P = .13).
Conclusions and Relevance: Treatment with aldosterone antagonists is associated
with a mortality benefit in patients with STEMI with LVEF greater than 40% or
without heart failure.

DOI: 10.1001/jamainternmed.2018.0850 
PMCID: PMC6145720
PMID: 29799995  [Indexed for MEDLINE]