Spironolactone Use and Improved Outcomes in Patients with Heart Failure with Preserved Ejection Fraction with Resistant Hypertension

The prevalence of heart failure with preserved ejection fraction (HFpEF) is increasing. These patients are commonly diagnosed with resistant hypertension and blood pressure management in such patients is difficult. Previous data suggest that spironolactone use in these patients in addition to lowering blood pressure may reduce the risk of heart failure and cardiovascular events. Tetsuro Tsujimoto and colleagues conducted a study titled “Spironolactone Use and Improved Outcomes in Patients with Heart Failure with Preserved Ejection Fraction with Resistant Hypertension” published in the Journal of the American Heart Association. The summary of this study is given below:

Objective:

To investigate whether spironolactone use leads to positive cardiovascular outcomes in patients with HFpEF with resistant hypertension.

Method:

This research was a secondary analysis of the trial named TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist). Patients with heart failure with HFpEF with and without resistant hypertension were included in the study. Systolic blood pressure ≥130 mm Hg and/or diastolic blood pressure ≥80 mm Hg was defined as resistant hypertension in a patient with hypertension despite the concurrent use of a renin-angiotensin system blocker, a diuretic, and a calcium channel blocker; or as those patients using ≥4 classes of antihypertensive medication. The main outcome was a composite of cardiovascular death, aborted cardiac arrest, or heart failure hospitalization.

Findings:

The study reports that spironolactone use in patients with HFpEF with resistant hypertension was associated with a decreased risk of composite cardiovascular events as compared to those without resistant hypertension. Additionally, spironolactone also led to a reduced risk of all-cause death and hospitalization for heart failure in patients with HFpEF with resistant hypertension. This beneficial effect of spironolactone was also noticed in patients with concurrent use of an ACEI/ARB, a CCB, and a diuretic.

Authors acknowledge future studies to investigate the association between spironolactone use and cardiovascular outcomes in patients with HFpEF. Spironolactone use was found to be associated with an increased risk of hyperkalemia and breast tenderness/enlargement. Closer laboratory monitoring and careful follow-up of patients were suggested with spironolactone use. Also, as resistant hypertension can be caused due to many reasons, spironolactone use must be considered after proper diagnosis.

Limitation:

A randomized controlled trial is required to confirm the findings as this was a secondary analysis of the TOPCAT study. Secondly, subjects with controlled blood pressure were included in the TOPCAT study, hence it is uncertain whether the results would be similar otherwise. There was no clarification regarding the doses of antihypertensive medications such as ACEIs, ARBs, CCBs, and diuretics. Additionally, there was a lack of information on antihypertensive medication classes other than ACEIs, ARBs, CCBs, diuretics, and beta-blockers.

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