Abstract 17979: Prognostic Value of Aldosterone Breakthrough in Systolic Heart Failure Patients
Purpose: Antagonism of the renin-angiotensin-aldosterone system (RAAS) represents a cornerstone of current therapy of heart failure (HF). Nonetheless, up to half of HF patients show elevated aldosterone level, despite the use of ACE-inhibitors (ACEi) or angiotensin receptor blockers (ARBs) ("aldosterone breaktrough”, AB). Data are lacking on AB influence on outcome: thus, we aimed to assess the prognostic value of AB in a systolic HF patients.
Methods: We selected 41 consecutive patients with systolic HF not receiving ACEi/ARBs at their first hospitalization (left ventricular ejection fraction, LVEF, 33±10%; age 64±14 years, m±SD; 80% males; NYHA class I-II 66%, III-IV 34%). Patients underwent a thorough clinical and neurohormonal (PRA, NT-proBNP, catecholamines, aldosterone) characterization at admission. Plasma aldosterone was reassessed after titration of ACEi/ARBs as well as of beta-blockers up to the maximum tolerated dose (median 183 days, range 49-453); AB was defined as aldosterone concentration above >180 ng/L (upper reference limit). All patients were followed-up (median 38 months; range 20-66) for cardiac death, death due to HF progression and the combination of sudden death and implantable cardioverter defibrillator (ICD) shock.
Results: In our population 19 (46%) patients showed AB. Patients with AB did not differ from those without as concerns clinical severity, etiology, LVEF, drug and device therapy, while they showed worse renal function (estimated glomerular filtration rate 55±20 vs 79±28 ml/min; p=0.004) and higher NT-proBNP level (851, 992-3458 vs 651, 368-2118 ng/L; p=0.044). During follow-up, 11 cardiac deaths (8 due to HF progression, 2 sudden deaths, 1 acute myocardial infarction) and 1 ICD shock were observed. At Kaplan-Meier analysis, patients with AB had a higher rate of cardiac death (p= 0.009) and death due to HF progression (p<0.001), but not of the composite end-point of sudden death and ICD shocks (p=0.130), compared to those without AB.
Conclusions: AB is frequently observed and may hold prognostic value in systolic HF patients. AB might identify subsets likely needing a tailored therapeutical effort, eventually using novel approaches acting on the RAAS, such as aldosterone synthase inhibitors.
- © 2013 by American Heart Association, Inc.