Mineralocorticoid Receptor Antagonists and Cardiovascular Mortality in Patients with Atrial Fibrillation and Left Ventricular Dysfunction: Insights from the AF-CHF Trial.
Circ Heart Fail. 2012 Jul 12;
Authors: O'Meara E, Khairy P, Chabot Blanchet M, Dedenus S, Pedersen OD, Levesque S, Talajic M, Ducharme A, White M, Racine N, Rouleau JL, Tardif JC, Roy D
BACKGROUND: -Patients with heart failure (HF) and atrial fibrillation (AF) may differ from the larger HF population with respect to comorbidities, including renal impairment, and overall prognosis. Associated cardiorenal interactions may mitigate the effects of pharmacological agents. Our primary objective was to assess the impact of mineralocorticoid receptor antagonists (MRA) on cardiovascular mortality in patients with AF and HF enrolled in the AF-CHF trial. METHODS AND RESULTS: -All 1,376 patients randomized in the AF-CHF trial were included. The median baseline creatinine was 105.2 (Q1 88.4, Q3 125.0) ?mol/L and the median estimated glomerular filtration rate (eGFR) was 62.3 (Q1 49.0, Q3 77.2) mL/min/1.73 m(2). Renal function was moderately or severely impaired (i.e., eGFR <60 mL/min/1.73 m(2)) in 46.5% of patients. In multivariable analyses, increased creatinine was associated with worsening HF but not mortality. MRA were prescribed in 44.8% and were independently associated with a 1.4-fold increase in total mortality [HR 1.4, 95% CI (1.1, 1.8), P= 0.005] and 1.4-fold increase in cardiovascular mortality [HR 1.4, 95% CI (1.1, 1.9), P=0.009]. This was driven by an increased incidence of sudden cardiac death [HR 2.0, 95% CI (1.3, 3.0), P=0.001]. CONCLUSIONS: -Renal dysfunction was highly prevalent in patients with AF and HF. MRA were independently associated with an increased incidence of cardiovascular deaths, predominantly of presumed arrhythmic etiology. While these provocative findings merit prospective validation, they underscore the importance of careful monitoring of renal function and electrolytes in patients with AF and HF receiving MRA.Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597077.
PMID: 22798522 [PubMed - as supplied by publisher]