Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction Post-ST-Segment-Elevation Myocardial Infarction

• Published in: Journal of the American Heart Association 2021-07, Vol.10 (14), p.e019167
• Main Authors: Wong, Eric C, Fordyce, Christopher B, Wong, Graham, Lee, Terry, Perry-Arnesen, Michele, Mackay, Martha, Singer, Joel, Cairns, John A, Turgeon, Ricky D
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Canada; Databases, Factual; Drug Prescriptions - statistics & numerical data; Eplerenone - therapeutic use; Female; Heart Failure - drug therapy; Heart Failure - physiopathology; Hospitalization; Humans; Logistic Models; Male; Middle Aged; Mineralocorticoid Receptor Antagonists - therapeutic use; Multivariate Analysis; Original Research; Prospective Studies; ST Elevation Myocardial Infarction - drug therapy; ST Elevation Myocardial Infarction - physiopathology; Stroke Volume; Treatment Outcome; Ventricular Dysfunction, Left - drug therapy; Ventricular Dysfunction, Left - physiopathology
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.120.019167

Background Guidelines recommend mineralocorticoid receptor antagonist (MRA) use in patients with left ventricular ejection fraction ≤40% following a myocardial infarction plus heart failure or diabetes mellitus, based on mortality benefit in the EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial. The objective of this study was to evaluate the real-world utilization of MRAs for patients with ST-segment-elevation myocardial infarction (STEMI) with left ventricular dysfunction. Methods and Results The prospective, population-based, Vancouver Coastal Health Authority STEMI database was linked with local outpatient cardiology records from 2007 to 2018. EPHESUS criteria were used to define post-STEMI MRA eligibility (left ventricular ejection fraction ≤40% plus clinical heart failure or diabetes mellitus, and no dialysis-dependent renal dysfunction). The primary outcome was MRA prescription among eligible patients at discharge and the secondary outcome was MRA prescription within 3 months postdischarge. Of 2691 patients with STEMI, 317 (12%) were MRA eligible, and 70 (22%) eligible patients were prescribed an MRA at discharge. Among eligible patients with no MRA at discharge, 12/126 (9.5%) with documented postdischarge follow-up were prescribed an MRA within 3 months. In multivariable analysis, left ventricular ejection fraction (odds ratio [OR], 1.55 per 5% left ventricular ejection fraction decrease; 95% CI, 1.26-1.90) and calendar year (OR, 1.23 per year, 95% CI, 1.11-1.37) were associated with MRA prescription at discharge. Other prespecified variables were not associated with MRA prescription. Conclusions In this contemporary STEMI cohort, only 1 in 4 MRA-eligible patients were prescribed an MRA within 3 months following hospitalization despite high-quality evidence for use. Novel decision-support tools are required to optimize pharmacotherapy decisions during hospitalization and follow-up to target this gap in post-STEMI care.