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Scope: Heart failure (HF) is highly prevalent, especially in the elderly, and is associated with major morbidity and mortality. Mineralocorticoid receptor antagonists (MRAs) improve outcomes in patients with heart failure and reduced ejection fraction (HEFREF) but have not been studied specifically in elderly cohorts. We performed a systematic review to determine the efficacy and safety of MRAs in patients >65 years with HF.

Search methods: Data sources: Medline, EMBASE, CINAHL, Cochrane. Two independent reviewers screened articles for eligibility. Selected trials were scored for Quality Assessment. Inclusion criteria comprised randomised, placebo-control trials of MRAs in patients >65 years (or pre-specified subgroup analysis in patients >65 years) with symptomatic heart failure. Efficacy outcomes: mortality, hospitalisations, symptoms, functional capacity. Safety outcomes: hyperkalaemia, renal dysfunction.

Results: 655 articles were identified by the initial data search and a further six by other means. Of these, 625 were excluded on title/title plus abstract. Of the remaining 36, four met inclusion criteria. Spironolactone reduced mortality in patients >67 years with chronic severe HEFREF, whilst eplerenone reduced the composite of mortality and hospitalisations in patients >75 years with HEFREF and mild symptoms. In patients with HEFREF post-myocardial infarction, eplerenone reduced mortality with no difference, on sub-group analysis, in patients >65 years. In patients >67 years with heart failure and preserved ejection fraction (HEFPEF), spironolactone improved diastolic dysfunction but did not improve symptoms or functional capacity. The incidence of serious hyperkalaemia or severe renal dysfunction was not increased by MRAs in patients >65 years.

Conclusions: MRAs are effective and safe in selected patients >65 years with HEFREF, although these patients may not be representative of the typical elderly heart failure population. The effects of MRAs in HEFPEF and in very elderly patients with HEFREF remain uncertain and require further study.

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