Missed opportunities: low use of evidence-based treatment with eplerenone after myocardial infarction - a nationwide study

Abstract

Purpose: The aldosterone antagonist eplerenone reduces mortality and read-missions after acute myocardial infarction (MI) in patients with LVEF<40% and either symptomatic heart failure or diabetes mellitus, and is recommended by ESC guidelines. We investigated evidence-based use of eplerenone in a nationwide cohort of patients after first-time MI in Denmark. Methods: From national registers we included all patients with MI, aged >30 years and surviving >30 days. Indication for eplerenone was defined as claimed prescription of loop-diuretics in addition to either ACE-inhibitor or antidiabetic drugs, within 90 days after discharge. Use of eplerenone and other aldosterone antagonists was identified, and survival compared by Kaplan-Meier analysis Results: We included 49,479 patients (63% men, mean age 68.1±13.6 years) with a median follow-up of 1003 (IQR 420-1716) days. Treatment with eplerenone was indicated in 9,115 (18.4%) patients, of which 93 (1.02%) received eplerenone, and 2,157 (23.7%) received spironolactone. Mortality rates for groups with and without indication for eplerenone at one-year were 1,096 (16.0%) and 3,115 (8.1%), and at end of follow-up 2,871 (41.8%) and 8,680 (22.5%), respectively (Figure). Applying the evidence-based mortality reducing effect of eplerenone to our results, a potential of 164 and 431 deaths within the first year, and during long-term follow-up, respectively, could have been saved by guideline-recommended use of eplerenone. (Figure presented) Conclusions: In a nationwide cohort of post-MI patients, a low use of eplerenone was observed in patients with indication for treatment. Our findings suggest an unexploited potential in the treatment of high-risk group of patients, and therefore focus on initiation of evidence-based treatment is warranted.