The TRED-HF trial considerably narrowed the population deemed as being low risk for heart failure relapse following the withdrawal of guideline-directed medical therapy (GDMT). However, several key subgroups were underrepresented and some patients may still wish to attempt GDMT withdrawal, especially in the setting of adverse effects or excess costs. In this post, we explore three questions that can be used to guide a shared decision-making process regarding GDMT withdrawal.
Cardiovascular disease is the leading cause of morbidity and mortality in patients with end stage renal disease (ESRD). A significant number of patients with ESRD undergoing dialysis have reduced left ventricular ejection fraction. Contemporary treatment of heart failure with reduced ejection fraction (HFrEF) includes multiple pharmacotherapeutic strategies such as renin-angiotensin-aldosterone system inhibitors to reduce mortality and slow disease progression. However, because of concerns about hyperkalemia, aldosterone receptor antagonists are not commonly used in patients with HFrEF and ESRD undergoing dialysis. This blog summarizes the current evidence for efficacy and safety of aldosterone receptor antagonists in patients with concomitant HFrEF and ESRD requiring dialysis.
Agents such as patiromer and sodium zirconium cyclosilicate can reduce serum potassium concentrations. But do they have a role in patients with heart failure with reduced ejection fraction (HFrEF)? In this piece, we explore whether these agents could reduce the risk of hyperkalemia when initiating, continuing, or dose-titrating guideline-directed medical therapies in HFrEF.
In Part 1 of this two-part series, we dissected the evidence behind the use of MRAs in HFrEF, HFpEF and MI to further understand the reasons for their underutilization and alleviate some of those concerns. In Part 2, the use of MRAs in resistant hypertension will be discussed, as well as considerations regarding blood pressure, potassium, and renal effects given these may play key roles in precluding MRA use when warranted.
Mineralocorticoid receptor antagonists are arguably one of the most underutilized medication classes despite sound evidence supporting their use across a spectrum of cardiovascular diseases. Part 1 of this two-part series chronicles current evidence evaluating the use of MRAs, particularly spironolactone, in the treatment of heart failure (both chronic and acute settings) and myocardial infarction.