1 / 18

Heart failure post Myocardial Infarction

Heart failure post Myocardial Infarction. ALDOSTERONE ANTAGONISTS Raj Chahal 14/02/2012. Heart failure is a complex clinical syndrome that suggests inefficiency of the heart pump. Can occur with reduced or preserved EF%. Most evidence on treatment is in patients with low EF% (LVSD).

zavad
Download Presentation

Heart failure post Myocardial Infarction

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Heart failure post Myocardial Infarction ALDOSTERONE ANTAGONISTS Raj Chahal 14/02/2012

  2. Heart failure is a complex clinical syndrome that suggests inefficiency of the heart pump. • Can occur with reduced or preserved EF%. • Most evidence on treatment is in patients with low EF% (LVSD). • In the UK, CAD is the leading cause of heart failure, many have had MI in the past. • Heart failure accounts for a total of 1 million inpatient bed‑days • 2% of all NHS inpatient bed-days • 5% of all emergency medical admissions to hospital.

  3. UK prevelance ~900000 • Expected to rise with increasing aging population • Average age on diagnosis 76 • Poor prognosis • 30–40% of patients diagnosed with heart failure die within a year • Then reduces down to ~10% /year • Overall improving mortality • The 6-month mortality rate decreased from 26% in 1995 to 14% in 2005

  4. Aldosterone promotes • retention of Na, • loss of Mg and K, • sympathetic activation, • parasympathetic inhibition, • myocardial and vascular fibrosis, • baroreceptor dysfunction, and • vascular damage and • impairs arterial compliance. Aldosterone

  5. Pitt et al 1999 • RALES trial (Randomized Aldactone Evaluation Study) • NEJM 1999;341:709 • Double blinding placebo RCT • Spiro v Placebo in NYHA 3-4, Sev LVSD • 1663 patients • Discontinued early after mean f/u 24/12 Known benefits with Aldosterone Blockers in heart failure

  6. There were 386 deaths in the placebo group (46 percent) and 284 in the spironolactone group (35 percent); • Relative risk of death, 0.70 (0.60 to 0.82; P<0.001) • Reduction in heart failure symptoms and hospitalizations for heart failure (35% relative risk)

  7. Eplerenone, a Selective Aldosterone Blocker, in Patients with Left Ventricular Dysfunction after Myocardial Infarction • Pitt et all • NEJM 2003;348:1309 • Eplerenone Post–Acute Myocardial Infarction Heart Failure Efficacy and Survival Study EPHESUS

  8. Multicenter, international, randomized, double-blind, placebo-controlled trial • Patients were randomly assigned to receive eplerenone (25 mg per day) or matching placebo for 4/52, • Then dose of eplerenone was increased to a maximum of 50 mg per day

  9. Day 3 – 14 post MI • LVSD - EF < 40% • Echo/ radionuclide/ angio • Heart failure • Rales/ CXR congestion/ 3rd HS • In diabetics heart failure did not need to be demonstrated • Optimal medical therapy (inc reperfusion) Inclusion criteria

  10. Use of K- sparing diuretic • Creatinine >220 • K > 5.0 Exclusion criteria

  11. Time to death, any cause • Time to death and hospitalization for any cardiovascular cause • HF/ MI/ Stroke/ Ventricular arrhythmia Primary Endpoints

  12. Death from cardiovascular causes • Death from any cause or any hospitalization Secondary Endpoints

  13. A total of 6642 patients underwent randomization at 674 centers in 37 countries • Between December 27, 1999, and December 31, 2001. • A total of 3313 were assigned to placebo, 3319 were assigned to eplerenone

  14. A total of 478 patients in the eplerenone group (14.4 percent) and • 554 patients in the placebo group (16.7 percent) died • (relative risk, 0.85; P=0.008) Death

  15. 885 patients in the eplerenone group (26.7 percent) and • 993 patients in the placebo group (30.0 percent) • (relative risk, 0.87; P=0.002) death from cardiovascular causes or hospitalization for cardiovascular events

  16. reduction in the risk of sudden death from cardiac causes was statistically significant (relative risk, 0.79; P=0.03) • fewer episodes of hospitalization for heart failure in the eplerenone group than in the placebo group (relative risk, 0.77; P=0.002) • rate of death from any cause or any hospitalization was 8 percent lower in the eplerenone group than in the placebo group (relative risk, 0.92; P=0.02) Other endpoints

  17. At one year, the creatinine had increased by 1.8 μmol/L in the placebo group and by 5.3 μmol/L in the eplerenone group (P<0.001) • Serious hyperkalemia (>6.0) occurred in 5.5% in the eplerenone group, and 3.9% in placebo group (P=0.002). Safety

  18. Has my patient had an MI in the last 3-14 days? • Did my patient have signs of HF or is diabetic? • Has my patient had an echo post MI with mod-sev or sev LVSD? • then think EPLERENONE • Px if K <5 & Creat <220 • ON TOP OF optimised b.blocker and ACEi • Monitor UEs • Refer to HFSN Clinical use

More Related