Key result
Eplerenone linked to ~17% lower all-cause mortality vs spironolactone in HFrEF.
Why the study?
MRAs are recommended as guideline-directed medical therapy for HFrEF, but the comparative effectiveness of spironolactone and eplerenone remains uncertain.
Does eplerenone reduce all-cause mortality compared to spironolactone in patients aged ≥45 years with HFrEF?
Population
4550 patients initiating eplerenone and 6651 initiating spironolactone with HFrEF aged ≥45 years
Comparison
Initiation of eplerenone vs initiation of spironolactone
Design
Nationwide non-interventional database study with active-comparator new-user design
Follow-up
Median 2.3 years
Authors
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Should not alter MRA choice toward eplerenone in HFrEF; leaves open need for randomized head-to-head trials.**[[1]](https://pubmed.ncbi.nlm.nih.
Cohort (n=11,201)
Yes
Does eplerenone reduce all-cause mortality compared to spironolactone in patients aged ≥45 years with HFrEF?
Effect estimate: wHR 0.83 (95% CI 0.75-0.93)
Absolute Event Rate: 5% vs 7%
In a nationwide observational study of HFrEF patients, eplerenone was associated with lower all-cause and cardiovascular mortality compared to spironolactone, potentially driven by better treatment persistence.
Svanström et al. (2026) conducted a cohort in Heart failure with reduced ejection fraction (HFrEF) (n=11,201). Eplerenone vs. Spironolactone was evaluated on All-cause mortality (wHR 0.83, 95% CI 0.75-0.93). Initiation of eplerenone was associated with a lower risk of all-cause mortality compared with spironolactone in patients with HFrEF (wHR 0.83; 95% CI 0.75-0.93).
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