Mineralocorticoid Receptor Antagonist Use in Patients with Diabetes Needs Closer Scrutiny

SAN FRANCISCO, CA—Patients with diabetes mellitus and reduced ejection fraction that received mineralocorticoid receptor antagonists (MRAs) “demonstrated a different clinical profile” compared with patients who did not receive an MRA, according to a presentation at ACC.13, the American College of Cardiology's 62nd Annual Scientific Session.

Concerns related to MRAs in the diabetic population limit their use in patients with heart failure despite the benefits. “The differential association between MRA use and outcomes in patients with diabetes mellitus in this observation study warrants prospective evaluation,” the investigators concluded.

Noting that the characteristics and outcomes of patients with diabetes who receive MRAs are not well known, Robert J. Mentz, MD, of Duke University Medical Center, Durham, NC, and colleagues analyzed 1,998 patients with reduced ejection fraction in the placebo arm of EVEREST (Efficacy of Vasopressin Antagonism in hEart failuRE) by diabetes status and whether or not they received a MRA at discharge. In EVEREST, 38% of patients had diabetes (n=750), of which 58% had received MRAs (n=433).

They investigated patient characteristics and outcomes, including all-cause mortality and cardiovascular mortality/hospitalization for heart failure over a median follow-up of 9.9 months.

Patients with diabetes who had received an MRA were more often female (28% vs. 21%), with non-ischemic etiology (68% vs. 77%), and lower serum creatinine (1.2mg/dL vs. 1.3mg/dL) than those who did not receive an MRA. Significantly more patients with diabetes were on an ACE inhibitor at discharge (87% vs. 78%); however, fewer had an implantable cardioverter defibrillator (14% vs. 23%; both P<0.001).

In patients with diabetes, MRA use was associated with lower all-cause mortality (HR 0.93; 95% CI, 0.75–1.15) and lower cardiovascular mortality/hospitalization for heart failure (HR 0.94; 95% CI, 0.8–1.1). The study authors concluded that the association between MRA use and outcomes in patients without diabetes mellitus was not significant (both P>0.2).

Lower morbidity and mortality was seen in diabetic patients receiving MRA compared to not receiving MRA. Dr. Mentz stated, “This study warrants the need for a prospective evaluation of MRA use and outcomes in diabetic and non-diabetic patients.”