Heart failure: the role for mineralocorticoid receptor antagonists

Mineralocorticoid receptor antagonists (MRA's) have been shown to be effective in patients with HFREF while their role in patients with HFPEF remains controversial. Despite a class one indication in both the ESC and AHA/ACC heart failure guidelines in patients with HFREF MRA's remain underused, in large part due to the fear of hyperkalaemia and renal dysfunction. While hyperkalaemia is a potential risk of MRA's, their use when potassium and renal function monitoring is properly carried out is minimal compared with their benefits in appropriate patients. New nonsteroidal MRA's and new potassium binding polymers currently under development hold the promise of further reducing the risks of hyperkalaemia while allowing higher doses of MRA's. They have been shown to overcome diuretic resistance and to potentially extend their benefits to patients with acute decompensated heart failure and those with chronic renal disease. While we await the results of studies with these new agents; application of current guidelines recommended therapies, including MRA's hold the best promise to further reduce cardiovascular mortality, hospitalisations for heart failure, and therefore, health care costs in patients with heart failure.