Introduction: Patients hospitalized for heart failure (HF) have increased risk for events post-discharge. Mineralocorticoid receptor antagonists (MRAs) have mortality benefits in patients with systolic HF. We assessed MRA use in high-risk patients identified by a HF hospitalization.
Methods: Patients admitted to UCSD Hospitals from 2011-2013 for systolic HF exacerbation were enrolled retrospectively through automated search of electronic medical records for appropriate ICD 9 and 10 codes. Of the 1250 patients identified, 444 had >1 year follow up in our clinics. Of these, 286 patients (65%) met inclusion criteria of LVEF<40% with NYHA class III-IV symptoms.
Results: At index hospital admission, 22.7% (65/286) were taking MRAs and 16.4% (47/286) had MRA initiated prior to discharge. Of the 176 patients not started on MRAs, 2 had hyperkalemia and 8 had CKD precluding MRA use per guideline recommendations. Patients taking MRAs (n = 112) did not have significantly different baseline characteristics than patients not taking MRAs (n = 174). Patients were followed for a median 3.54 ± 0.051 years. Only 27.7% (31/112) tolerated therapy for the duration of follow up, while 72.3% (81/112) experienced discontinuations. 63% (51/81) of patients discontinuing MRA therapy were able to restart it. However 30 patients had further or permanent discontinuations, with 23 discontinuations due to hyperkalemia. Compared to patients who tolerated MRA therapy with 1 or fewer discontinuations (n=82), patients with 2 or more discontinuations (n=30) had significantly higher rates of hyperkalemia per patient (1.17 ± 0.21 v. 0.75 ± 0.08; p = 0.0096), more hospitalizations from any cause (7.30 ± 0.86 v. 3.60 ± 0.36; p = 0.0003), from cardiovascular causes (5.07 ± 0.65 v. 2.50 ± 0.27; p = 0.0008) or from HF (4.85 ± 0.55 v. 2.09 ± 0.22; p < 0.0001), and they tended to have reduced survival (HR 0.42, 95% confidence interval 0.14-1.03; p=0.056).
Conclusions: Less than half of patients who were hospitalized for systolic HF received MRAs at discharge and there was a very high rate of MRA intolerance during follow-up. Hyperkalemia was the most common cause of MRA discontinuation. MRA intolerance was associated with worse clinical outcomes including more frequent hospitalizations and reduced survival.