Mineralocorticoid receptor antagonists in heart failure with sustained monomorphic ventricular tachycardia: comparative analysis of spironolactone versus eplerenone

Background Mineralocorticoid receptor antagonists (MRAs) are core therapy in chronic heart failure (HF) and reduce all-cause mortality and sudden cardiac death. However, direct comparisons of spironolactone and eplerenone in the context of ventricular arrhythmia recurrence are lacking. This study aims to compare the effects of these two MRAs on all-cause mortality and recurrence of sustained monomorphic ventricular tachycardia (VT) in patients with HF. Methods We analysed data of HF patients with left ventricular ejection fraction (LVEF) below 50%, hospitalised for sustained monomorphic VT and receiving MRA therapy at discharge. We performed propensity score matching for 13 variables, including medical history, medication and arrhythmia presentation. The endpoints were all‐cause mortality and VT recurrence. Results Among the 292 patients who met the selection criteria, 202 were included in the final analysis after propensity score matching, representing 69% of the eligible cohort. Median age was 67 (61–74) years and 87% were male. The median LVEF was 30% (25%–35%). The median follow‐up duration was 32 (18–36) months, with a minimum follow‐up of 1 year. During follow-up, 70 patients died, while VT recurrence was observed in 86 patients. There was no significant difference in all-cause mortality between the two MRAs (HR 0.98 (0.62 to 1.57), p=0.94). However, eplerenone was associated with a significantly lower risk of VT recurrence compared with spironolactone (HR 0.42 (0.26 to 0.66), p<0.001, Fine-Gray adjusted HR 0.36 (0.22 to 0.59), p<0.001). Conclusions In HF patients with sustained monomorphic VT, eplerenone was associated with fewer VT recurrences than spironolactone, without differences in all-cause mortality.