Cardiovascular effects of mineralocorticoid receptor antagonists in acute coronary syndrome: an updated systematic review and meta-analysis of randomized clinical trials.

BACKGROUND

Mineralocorticoid receptor antagonists (MRA) have proven efficacy in heart failure and post-infarct left ventricular dysfunction, but their broader impact in acute coronary syndrome (ACS) remains uncertain.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing MRA versus placebo in patients following ACS. The primary endpoint was a composite of cardiovascular death, heart failure, or significant arrhythmia. Secondary endpoints included individual cardiovascular outcomes, recurrent myocardial infarction, stroke, all-cause mortality, ventricular remodeling parameters, and adverse events. PROSPERO registry CRD420251149760.

RESULTS

Nine trials with 16,882 patients were included. Treatment with MRA significantly reduced the risk of the composite cardiovascular endpoint (RR 0.89, 95% CI 0.83-0.96; p = 0.001). This effect was primarily driven by reductions in cardiovascular mortality and heart failure events; no significant effect was observed for arrhythmias. Also, MRA lowered all-cause mortality (RR 0.88, 95% CI 0.80-0.97; p = 0.009) and improved left ventricular remodeling indices (increase in LVEF, reductions in LVESV/LVEDV). MRA did not significantly affect recurrent myocardial infarction or stroke. Safety analysis showed an increased risk of hyperkalemia (RR 2.14, 95% CI 1.45-3.16; p < 0.001) but no significant differences in overall or serious adverse events versus placebo.

CONCLUSIONS

In patients with ACS, MRA therapy confers a significant reduction in composite cardiovascular events and all-cause mortality, with favorable remodeling effects and a safety profile consistent with known risks (notably hyperkalemia). These results support guideline-aligned use of MRA in post-ACS management, with appropriate monitoring strategies.