The Role of Aldosterone Blockade in Patients with Hypertensive Heart and Cardiovascular Disease

Aldosterone blockade has been shown to be effective in reducing total mortality in patients with severe heart failure due to systolic left ventricular dysfunction and in patients with heart failure post myocardial infarction. Increasing evidence suggests that aldosterone blockade alone and or in conjunction with an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) with or without a thiazide diuretic may also prevent target organ damage (TOD) in patients with hypertensive heart disease (HHD) independent of its effects on blood pressure. Aldosterone blockade may be of especial value in patients with resistant hypertension, visceral obesity, and sleep apnea. Aldosterone blockade prevents myocardial fibrosis and improves echocardiographic indices of diastolic function in patients with heart failure and a normal left ventricular ejection fraction (HFNEF). Its effects on cardiovascular mortality and hospitalization for heart failure in HFNEF are currently under investigation. Aldosterone blockade has also been shown to be beneficial in preventing experimental atherosclerosis and in limiting experimental stroke, although not as yet in man. Although aldosterone may cause serious hyperkalemia this is unlikely in patients with normal renal function. Nevertheless careful selection of patients and serial monitoring of serum potassium, especially in patients with chronic kidney disease, is essential if one is to obtain benefit from this strategy. The risk/benefit of aldosterone blockade alone and or in combination with an ACE-I or ARB with or without a thiazide diuretic in patients with HHD will however require further large scale prospective randomized study.