The ARTS of third-generation mineralocorticoid receptor antagonists: achieving cardiovascular benefit with minimized renal side effects?

Abstract

This editorial refers to ‘Safety and tolerability of the novel non-steroidal mineralocorticoid receptor antagonist BAY 94-8862 in patients with chronic heart failure and mild or moderate chronic kidney disease: a randomized, double-blind trial,’[†][1] by B. Pitt et al. , on page 2453 The mineralocorticoid receptor antagonists (MRAs) spironolactone and eplerenone have been proven to reduce total mortality and hospitalization in three large randomized controlled trials in patients with symptomatic chronic heart failure and patients with left ventricular dysfunction and heart failure symptoms early after myocardial infarction. This marked and sustained evidence-proven benefit led to the class I recommendation for MRAs in the treatment of all patients with symptomatic systolic heart failure already treated with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers.1−3 Despite considerable efforts to enable the broad application of these life-saving medications in all patients with systolic heart failure,4 many clinicians are still reluctant to employ MRAs in their clinical practice.5 While these restraints are hard to understand in heart failure patients with normal kidney function, worsening renal function and hyperkalaemia are significant clinical problems in patients with mild to moderate, and especially with severe, renal dysfunction. However, when contraindications such as co-medication with potassium-sparing diuretics are respected and renal function and potassium levels are closely followed, patients with mild to moderate renal insufficiency appear to gain similar reductions in mortality and hospitalization by MRA treatment as heart failure patients with normal renal function.6 Although patients with severe renal dysfunction had been excluded from the mortality … [1]: #fn-2