Pitt Bertram, Bakris George, Ruilope Luis M, DiCarlo Lorenzo, Mukherjee Robin
University of Michigan Medical Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA.
Circulation. 2008 Oct 14;118(16):1643-50. doi: 10.1161/CIRCULATIONAHA.108.778811. Epub 2008 Sep 29.
Aldosterone blockade is recommended for patients with congestive heart failure after acute myocardial infarction complicated by left ventricular systolic dysfunction; however, the perceived risk of hyperkalemia may limit implementation of this therapeutic approach. This subanalysis examined the relationship between eplerenone, serum potassium (K(+)), and clinical outcomes in the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS).
Hospitalized patients with congestive heart failure after acute myocardial infarction complicated by left ventricular systolic dysfunction (left ventricular ejection fraction < or =40%) treated with standard therapy were randomized 3 to 14 days after the acute myocardial infarction to additional treatment with eplerenone (25 to 50 mg/d; n=3319) or placebo (n=3313). Patients were excluded if baseline K(+) was >5.0 mEq/L or serum creatinine was >2.5 mg/dL. In patients receiving standard therapy, the addition of eplerenone resulted in a 4.4% absolute increase in the incidence of K(+) >5.5 mEq/L, a 1.6% increase of K(+) > or =6.0 mEq/L, and a 4.7% absolute decrease in hypokalemia (K(+) <3.5 mEq/L). Four independent baseline predictors of hyperkalemia (defined as > or =6.0 mEq/L) were identified: potassium (K(+) greater than the median; 4.3 mEq/L), estimated glomerular filtration rate (< or =60 mL . min(-1) . 1.73 m(-2)), history of diabetes mellitus, and prior use of antiarrhythmic agents. None of these independent baseline risk factors significantly impacted the cardiovascular benefit of eplerenone for reducing all-cause mortality.
Use of selective aldosterone blockade with eplerenone within the dose range of 25 to 50 mg/d in post-acute myocardial infarction patients with heart failure and left ventricular systolic dysfunction who are treated with standard therapy improves outcomes without an excess of risk of hyperkalemia (> or =6.0 mEq/L) when periodic monitoring of serum K(+) is instituted.
对于急性心肌梗死后并发左心室收缩功能障碍的充血性心力衰竭患者，推荐使用醛固酮拮抗剂；然而，高钾血症的潜在风险可能会限制这种治疗方法的实施。本亚组分析在依普利酮急性心肌梗死后心力衰竭疗效和生存研究（EPHESUS）中研究了依普利酮、血清钾（K⁺）与临床结局之间的关系。
急性心肌梗死后并发左心室收缩功能障碍（左心室射血分数≤40%）且接受标准治疗的住院充血性心力衰竭患者，在急性心肌梗死后3至14天被随机分为接受依普利酮（25至50mg/d；n = 3319）或安慰剂（n = 3313）的额外治疗。如果基线K⁺>5.0mEq/L或血清肌酐>2.5mg/dL，则将患者排除。在接受标准治疗的患者中，加用依普利酮导致K⁺>5.5mEq/L的发生率绝对增加4.4%，K⁺≥6.0mEq/L的发生率增加1.6%，低钾血症（K⁺<3.5mEq/L）的发生率绝对降低4.7%。确定了高钾血症（定义为≥6.0mEq/L）的四个独立基线预测因素：钾（K⁺大于中位数；4.3mEq/L）、估计肾小球滤过率（≤60mL·min⁻¹·1.73m⁻²）、糖尿病病史和既往使用抗心律失常药物。这些独立基线危险因素均未显著影响依普利酮降低全因死亡率的心血管益处。
对于接受标准治疗的急性心肌梗死后心力衰竭且左心室收缩功能障碍的患者，在25至50mg/d的剂量范围内使用依普利酮进行选择性醛固酮阻断，在定期监测血清K⁺时，可改善结局且不会增加高钾血症（≥6.0mEq/L）的风险。
