Monday, November 15, 2010


The Annual Scientific meeting of the American Heart Association, is happening now at Chicago, till late this week. Amongst the many papers, there will be many presentations on heart failure, especially acute systolic heart failure. I have picked out one of them for mention.
Eplerenone, is a new aldosterone antagonist ( the old member being spironolactone ). We were thought to use spironolactone in the 1980s as a diuretic, together with frusemide, in an attempt to control salt and water retention, thereby lessening water-log symptoms like breathlessness, and leg swelling. Little did we know in then that, future studies will show to us that the major benefit of aldosterone antagonist, will be to increase survival, and lessen hospitalisation from heart failure. In this role, it has proven to be much better then ACE-I, and ARBs. This was very well shown in large clinical trials like " RALES " and " EPHESUS". These drugs ( ACE-I, ARBs and aldosterone antagonist, all act via the RAS system, which is deranged in systolic heart failure ). Looks like aldosterone antagonist, which works at the end of the pathway, reduces mortality the most. Interesting.
The latest study to be presented at AHA 2010, and also published on-line in New England J of Medicine 14th Nov., is the EMPHASIS-HF trial. The lead investigator is Dr Faiez Zannard of Nancy France, together with Dr Bertram Pitt of Chicago ( who also led the RALES study ). They studied 2737 patients with class 2 ( mild ) heart failure. These patients all have low LV systolic function ( LVEF <35% ). After 21 months of follow-up ( prematurely discontinued ), they found a 24 % reduction in CV mortality, 42% reduction in Heart failure hospitalisation, and a combined 37% reduction in CV death and HF hospitalisation. This is very significant. If this is true, all patients with systolic HF should get aldosterone antagonist. Of course, spironolactone is cheap, but Eplerenone is expensive.
Another Heart Failure study to be presented at AHA 2010, Chicago, is the ASCEND-HF study, with the use of a vaso-dilator, nesiritide, , in acute systolic heart failure. This study came out negative again, like the previous study on nesiritide. Looks like this expensive vaso-dilator, nesiritide, even if it makes it to the market, will only have very limited, use, as the cost does not justify, the lack of good clinical evidence.
Lets see what else AHA 2010 will bring. As far as I can see, nothing much.
I wish them a very successful AHA 2010 meeting, but.....................

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