LETTER TO THE EDITOR
Use of spironolactone in heart failure patients receiving angiotensin-converting enzyme inhibitors and beta-blockers
Ali Ahmed, MD, MPH, FACP
Division of Geriatric Medicine and, Geriatric Heart Failure Clinic, University of Alabama at Birmingham, Birmingham Veterans Affairs Medical Center, 1530 3rd Avenue South, CH19-219, Birmingham, AL 35294-2041, USA
aahmed{at}uab.edu
We read with great interest the report by Bozkurt et al. (1) which raises important issues related to translation of research findings into clinical practice. This is especially important for the use of spironolactone for patients with heart failure and left ventricular systolic dysfunction who are already receiving a beta-blocker. The investigators demonstrated significant dissimilarities between patients enrolled in the Randomized Aldactone Evaluation Study (RALES) and clinical practice, which might have resulted in increased adverse effects. However, perhaps the single most important variable, the increasing dissimilarity of which will likely determine the future role of spironolactone in heart failure patients, is use of beta-blockers. Only 11% of the RALES participants were receiving a beta-blocker (2). The American College of Cardiology and American Heart Association heart failure guidelines recommend that all stable patients with heart failure and left ventricular systolic dysfunction should receive a beta-blocker unless specific contraindication exists (3). The weight of evidence for use of a beta-blocker is stronger than that for spironolactone, and it is expected that appropriate use of beta-blocker will increase in the future. Data from the Valsartan Heart Failure Trial (Val-HeFT) demonstrated that extensive blockade of multiple neurohormonal systems in patients with heart failure may not be desirable and may be associated with adverse outcomes (4). In the Val-HeFT study, among patients receiving both an angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker at baseline, use of valsartan was associated with over 40% increase in the risk of death (p = 0.009) and nearly 20% increase in the risk of combined end point of mortality and morbidity (p = 0.10). The impact of use of spironolactone on heart failure patients already receiving an ACE inhibitor and a beta-blocker is currently unknown. New randomized controlled trials should be conducted before spironolactone could be recommended for such patients.
The study also highlighted that hasty adoption of research findings might result in poor quality of care as it could be the result of a delayed adoption, as in the case with ACE inhibitors and beta-blockers. Underutilization of evidence-based therapy has often been associated with perceived contraindications or fears of adverse effects (5). It is hoped that future studies would examine underlying reasons associated with hasty and inappropriate adoption of evidence-based therapy.
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- Bozkurt B, Agoston I, Knowlton A. Complications of inappropriate use of spironolactone in heart failure: when an old medicine spirals out of new guidelines. J Am Coll Cardiol. 2003;41:211–214[Abstract/Free Full Text]
- Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study investigators. N Engl J Med. 1999;341:709–717[Abstract/Free Full Text]
- Hunt SA, Baker DW, Chin MH, et al. ACC/AHA guidelines for the evaluation and management of chronic heart failure in the adult: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1995 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2001;38:2101–2113[Free Full Text]
- Cohn JN, Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med. 2001;345:1667–1675[Abstract/Free Full Text]
- Ahmed A, Kiefe CI, Allman RM, Sims RV, DeLong JF. Survival benefits of angiotensin-converting enzyme inhibitors in older heart failure patients with perceived contraindications. J Am Geriatr Soc. 2002;50:1659–1666[CrossRef][Medline]
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