Safety and efficacy of early initiation of mineralocorticoid receptor antagonist after an acute decompensated heart failure event or acute myocardial infarction with cardiac dysfunction: a meta-analysis of randomized clinical trials.

BACKGROUND AND AIMS: To conduct a meta-analysis of randomized controlled trials (RCTs) to evaluate the impact of mineralocorticoid receptor antagonists (MRAs) initiation in patients with heart failure (HF) within a few weeks after a decompensation event or acute myocardial infarction with cardiac dysfunction.

METHODS

Four electronic databases were screened for eligible studies. Randomized controlled trials were included if they assessed MRA initiation either during an index hospitalization for HF or within 60 days following a first episode of HF decompensation or acute myocardial infarction with newly documented left ventricular dysfunction (i.e. <50%). When RCTs did not fulfil the eligibility criteria, subgroup analyses were examined and included if eligible. Efficacy endpoints were all-cause death, worsening HF, and length of hospital stay. Safety endpoints included worsening renal failure, hypokalaemia, and hyperkalaemia. A pre-specified subgroup analysis for efficacy endpoints was planned by clinical setting (acute ischaemic vs non-ischaemic HF). Six RCTs with 9770 patients were included.

RESULTS

Early MRA use was associated with a significantly lower risk of hypokalaemia [risk ratio (RR) 0.39, 95% confidence interval (CI) 0.26-0.58], without increasing the risk of worsening renal failure or hypotension, but with a modest increase in hyperkalaemia risk. Mineralocorticoid receptor antagonist initiation within 60 days after decompensation significantly reduced the risk of all-cause death (RR 0.87, 95% CI 0.79-0.95) and worsening HF (RR 0.81, 95% CI 0.72-0.91), with no effect on hospital length, when compared with usual care. These benefits were consistent in acute ischaemic vs non-ischaemic HF.

CONCLUSIONS

Early MRA initiation was associated with improved prognosis when compared with usual care, though accompanied by an increased risk of hyperkalaemia, warranting close follow-up after initiation.

PROSPERO REGISTRATION NUMBER: CRD42025649719.