Spironolactone in Heart Failure with Preserved Ejection Fraction

Nearly 50% of patients with HF have preserved EF (HFpEF). Unfortunately, to date, no treatment has been shown to improve outcomes in this condition.

In Aldo-DHF trial aldosterone blockade failed to improve exercise capacity, symptoms, or quality-of-life measures in a placebo-controlled trial of >400 patients with HFpEF (LVEF >50%, NYHA II-III). However, long term spironolactone treatment in the study led to significant gains in echocardiographic measures of diastolic function.

Recently, the large randomized, double-blind TOPCAT study investigated the prognostic role of spironolactone in patients with HFpEF. In this trial, 3445 patients with symptomatic heart failure and a left ventricular ejection fraction of 45% or more were assigned to receive either spironolactone or placebo. There was no overall benefit of spironolactone regarding the primary outcome composite measure. Neither the time to first hospitalization for any reason nor the time to death from any cause was significantly altered by random assignment to spironolactone. On the other hand spironolactone therapy however raised serum creatinine levels and risk of hyperkalemia.

Cat on the Top--TOPCAT  :)

These disappointing results of Aldo-DHF and TOPCAT uprooted my hope that spironolactone has ‘some but not great’ benefit in HFpEF. And still the cornerstone of treatment of this entity revolves around treatment of underlying cause and symptom guided therapy.

TOPCAT. N Engl J Med 2014; 370:1383-1392

Aldo-DHF trial JAMA 2013; 309:781-791.