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Little encouragement for added aldosterone blockade in acute MI

ESC Congress News 2015 - London

The addition of mineralocortoid receptor antagonists (MRAs) to standard therapy offers no benefit in acute MI patients without heart failure, according to the Aldosterone Lethal effects Blockade in Acute myocardial infarction Treated with or without Reperfusion to improve Outcome and Survival at Six months follow-up (ALBATROSS) trial presented yesterday at a Hot Line session

Coronary Artery Disease, Acute Coronary Syndromes, Acute Cardiac Care

Gilles Montalescot: Study results ‘do not warrant’ extension to MI patients without HF.Principal investigator Gilles Montalescot from the Institut de Cardiologie, Centre Hospitalier Universitaire Pitie-Salpetriere in Paris, France, said the results from ALBATROSS, which is the largest study of its kind, ‘do not warrant the extension’ of aldosterone blockade to MI patients without heart failure.

Also known as aldosterone antagonists, MRAs inhibit sodium retention and excretion of potassium and magnesium. Previous studies have demonstrated they reduce mortality in MI patients with congestive heart failure but little is known about this treatment in the absence of heart failure.

The aim of ALBATROSS was thus to investigate the effects of prolonged MRA therapy initiated early after the onset of MI in a patient population which included 92% presenting without heart failure.

Researchers randomised patients to standard therapy alone (n = 801) or with the addition of aldosterone blockade (n = 802), which consisted of intravenous K+ canrenoate (200 mg) followed by an initial 25 mg dose of oral spironolactone then daily for six months. Some patients were randomised in the ambulance to ensure this took place as early as possible.

Standard therapy included in-hospital medications, coronary angiography, PCI and coronary bypass grafting. The primary endpoint was death, resuscitated cardiac death, VF/VT, indication for defibrillator, and heart failure at up to six month follow-up.

Median follow-up of 118 days showed that the primary outcome rate was 11.8% in the aldosterone blockade group and 12.2% in the control group (HR 0.97; P=0.81). However, the study did find that early aldosterone blockade reduced mortality in STEMI patients (n = 1229; HR 0.20; 95% CI 0.06-0.70).

Montalescot urged caution in interpreting this finding, although a potential benefit is plausible in this patient group.