Response to Eplerenone in Patients With Acute Myocardial Infarction Complicated by Heart Failure
Ramaraj1 raises concerns regarding our recommendation to use eplerenone in patients with left ventricular systolic dysfunction and heart failure postmyocardial infarction (MI)2 based on the increase in the incidence of serious hyperkalemia noted by Juurlink et al3 and others when an aldosterone blocker was administered to patients with chronic heart failure.
We agree with him that an estimated glomerular filtration rate should be calculated, especially in the elderly, before considering the use of eplerenone in a patient post-MI. However, we also emphasize that, when the recommended initial dose of eplerenone is chosen (25 mg/d) for patients post-MI, excluding those with a serum potassium >5.0 meq/L and or an estimated glomerular filtration rate ≤30 mL/min per 1.73 m2, and serum potassium is serially monitored as recommended,4 the drug is associated with a significant decrease in all-cause mortality, especially in those patients with a history of hypertension.2 In both the Randomized Aldactone Evaluation Study5 and the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study,4 the use of an aldosterone blocker was associated with a significant reduction in all-cause mortality without a single death attributable to hyperkalemia. A more detailed analysis of the effects of eplerenone on serum potassium and the occurrence of hyperkalemia in patients post-MI is available.6
If physicians are willing to follow the relatively simple dosing, inclusion, and exclusion criteria outlined in the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study, monitor serum potassium, and adjust the dose of eplerenone accordingly, the evidence is clear that eplerenone is beneficial in patients with left ventricular systolic dysfunction and heart failure post-MI.4 It would indeed be unfortunate if a potentially life-saving strategy such as eplerenone were withheld from a patient with left ventricular systolic dysfunction and heart failure post-MI because of unfounded fears of hyperkalemia induced in large part by physicians who failed to adhere to the simple inclusion and exclusion criteria and the monitoring strategy for serum potassium as outlined in the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study.
B.P. is a consultant to Pfizer.
Ramaraj R. Eplerenone in patients with acute myocardial infarction complicated by heart failure. Hypertension. 2008; 52: e147.
Pitt B, Ahmed A, Love TE, Krum H, Nicolau J, Cardoso JS, Parkhomenko A, Aschermann M, Corbalan R, Solomon H, Shi H, Zannad F. History of hypertension and eplerenone in patients with acute myocardial infarction complicated by heart failure. Hypertension. 2008; 52: 271–278.
Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, Bittman R, Hurley S, Kleiman J, Gatlin M; Eplerenone Post–Acute Myocardial Infarction Heart Failure Efficacy and Survival Study Investigators. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003; 348: 1309–1321.
Pitt B, Bakris G, Ruilope LM, DiCarlo L, Mukherjee R. Serum potassium and clinical outcomes in the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS). Circulation. 2008; 118: 408–416.