[Skip to Navigation]
Comment & Response
November 2018

Mineralocorticoid Receptor Antagonism Treatment for All Patients With ST-Segment Myocardial Infarction?

Author Affiliations
  • 1Department of Cardiology, Hairmyres Hospital, Lanarkshire, Scotland
JAMA Intern Med. 2018;178(11):1567. doi:10.1001/jamainternmed.2018.5950

To the Editor Dahal and colleagues1 attempt to shed more light on whether mineralocorticoid receptor antagonism (MRA) benefits outcomes in acute myocardial infarction (MI) with left ventricular ejection fraction (LVEF) greater than 40%, but without heart failure, focusing on ST-segment elevation MI (STEMI).1 The conclusion of this meta-analysis—that MRA confers a mortality benefit in this group—is somewhat controversial given that none of the 10 trials included showed any mortality benefit in such patients; only 1 (ALBATROSS) suggested a mortality benefit in a nonprespecified STEMI subgroup.2 Moreover, there is significant heterogeneity in MRA prescribed, time to commencing MRA, reperfusion and revascularization strategies, and medical therapy, all known to influence outcome. The benefits of eplerenone therapy begun 3 to 14 days post-MI in the landmark EPHESUS trial were confined to those who began MRA treatment between days 3 and 7.3 Day 1 eplerenone treatment reduced a composite clinical/biochemical end point measure in patients with STEMI in REMINDER, driven by reductions in natriuretic peptides but without any mortality benefit.4 The results of the meta-analysis by Dahal and colleagues1 must therefore be interpreted with considerable caution.

Add or change institution