The role of mineralocorticoid receptor antagonists in patients with acute myocardial infarction: is the evidence reflective of modern clinical practice?

Heart failure (HF) and ischaemic heart disease (IHD) are among the leading causes of death globally [1,2]. Despite improvements in the prevention and management of IHD, it remains the commonest cause of HF [2,3]. The prognosis, once a diagnosis of HF is established, is limited with only 50% surviving to 5 years and 10% to 10 years [2]. It is therefore critical that interventional cardiologists not only focus on appropriate revascularisation strategies but also optimal medical therapy to prevent and/or treat HF. Spironolactone, the first available mineralocorticoid receptor antagonist (MRA), has been available for over 50 years when it was used solely in states of hyperaldosteronism [4]. Since then the class has expanded and their role in the medical management and prevention of HF has been firmly established [4]. However, despite the recommendations of both the European Society of Cardiology (ESC) and the American Heart Association (AHA) to initiate eplerenone early after acute myocardial infarction (AMI) associated with left ventricular systolic dysfunction, there are concerns that there is a mismatch between the evidence base behind these recommendations and contemporary management of patients with AMI particularly with regard to revascularisation and speed of discharge [5–7].