Department of Internal Medicine, Maimonides Medical Center, Brooklyn, NY 11220, USA.
Am J Med. 2012 Aug;125(8):817-25. doi: 10.1016/j.amjmed.2011.12.018.
Eplerenone is publicized to be extremely effective in reducing mortality from heart failure, with a reasonable side-effect profile. However, it is much more expensive compared with older aldosterone antagonists. We reviewed available evidence to assess whether increased expense was justified with outcomes data.
The authors searched the PubMed, CENTRAL, CINAHL, and EMBASE databases for randomized controlled trials from 1966 through July 2011. Interventions included aldosterone antagonists (Aldactone [Pfizer, NY, NY], canrenone, eplerenone) in systolic heart failure. The comparator included standard medical therapy or placebo, or both. Outcomes assessed were mortality in the intervention versus the comparator groups, and rates of adverse events at the end of at least 8 weeks of follow-up. Event rates were compared using a forest plot of relative risk (RR) (95% confidence interval [CI]) using a random-effects model (Mantel-Haenszel) between the aldosterone antagonists and controls. We included 13 studies for aldosterone antagonists other than eplerenone, and 3 studies for eplerenone. There was significant reduction of mortality with all aldosterone antagonists, but eplerenone (15% mortality relative reduction; RR 0.85; 95% CI, 0.77-0.93; P=.0007) was outperformed by other aldosterone antagonists, namely, spironolactone and canrenone (26% mortality relative reduction; RR 0.74; 95% CI, 0.66-0.83; P <.0001). Reduction in cardiovascular mortality with eplerenone was 17% (RR 0.83; 95% CI, 0.75-0.92; P=.0005), while that with other aldosterone antagonists was 25% (RR 0.75; 95% CI, 0.67-0.84, P <.0001), without contributing significantly to an improved side-effect profile.
Eplerenone does not appear to be more effective in reducing clinical events compared with older, less expensive aldosterone antagonists.
依普利酮被宣传为在降低心力衰竭死亡率方面非常有效，且副作用谱合理。然而，与较老的醛固酮拮抗剂相比，它的价格要高得多。我们回顾了现有证据，以评估使用结局数据来增加费用是否合理。
作者检索了 1966 年至 2011 年 7 月的 PubMed、CENTRAL、CINAHL 和 EMBASE 数据库，以寻找随机对照试验。干预措施包括在收缩性心力衰竭中使用醛固酮拮抗剂（醛固酮拮抗剂[辉瑞，纽约，NY]、坎利酮、依普利酮）。比较组包括标准的医疗治疗或安慰剂，或两者都有。评估的结局包括干预组与对照组的死亡率，以及至少 8 周随访结束时不良事件的发生率。使用森林图比较相对风险（RR）（95%置信区间[CI]），使用随机效应模型（Mantel-Haenszel）比较醛固酮拮抗剂和对照组之间的事件率。我们纳入了 13 项除依普利酮以外的醛固酮拮抗剂研究，和 3 项依普利酮研究。所有醛固酮拮抗剂均显著降低死亡率，但依普利酮（死亡率相对降低 15%；RR 0.85；95%CI，0.77-0.93；P=.0007）优于其他醛固酮拮抗剂，即螺内酯和坎利酮（死亡率相对降低 26%；RR 0.74；95%CI，0.66-0.83；P<.0001）。依普利酮降低心血管死亡率 17%（RR 0.83；95%CI，0.75-0.92；P=.0005），而其他醛固酮拮抗剂降低 25%（RR 0.75；95%CI，0.67-0.84，P<.0001），但对改善副作用谱没有显著贡献。
与较老的、较便宜的醛固酮拮抗剂相比，依普利酮在降低临床事件方面似乎并不更有效。
