The effect of eplerenone vs irbesartan as first line therapy in obese hypertensive patients on left ventricular hypertrophy and diastolic dysfunction: echocardiographic results of the HEBRO randomized

Objective The pathophysiology of hypertension in obese patients is complex and multifactorial. Obesity is significantly associated with adverse cardiovascular outcomes. The relationship between obesity and hypertension is well described. However, little is known about the impact of aldosterone blockade using eplerenone in hypertensive obese patients as first line therapy. Purpose The aim of this study’s analysis is to compare the efficacy between eplerenone-based strategy and irbesartan-based strategy in obese hypertensive individuals, regarding regression of left ventricular hypertrophy and diastolic dysfunction. Methods HEBRO (antiHypertensive treatment with Eplerenone vs. iBesartan in hypeRtensive Obese patients) is a prospective, randomized, open-labeled, multicenter trial that enrolled 198 hypertensive patients aged 30 to 75 years old, with obesity (BMI ≥ 30 kg/m2) and arterial hypertension established by both office and ambulatory BP measurements. Patients were stratified randomized to either 25mg eplerenone bd (99 pts) or 150mg irbesartan od (99 pts). At 2 months and 4 months up-titration with amlodipine 5mg and indapamide 1.5mg respectively was taken place when mean ambulatory BP (ABPM) was over 130/80mmHg. The primary endpoint is the difference in diastolic function indices at 6-months follow-up period. Results At baseline, no statistically significant differences were observed between arms. Baseline left ventricular mass index (LVMI) was 79.59 ± 12.17 g/m² in the irbesartan arm and 80.59 ± 12.73 g/m² in the eplerenone arm (p = 0.583). Baseline left atrial volume index (LAVI) was also comparable between groups (29.03 ± 5.29 mL/m² vs. 29.79 ± 5.41 mL/m², respectively; p = 0.336). At 6 months, LVMI decreased by −5.84 ± 4.16 g/m² in the irbesartan group and by −6.71 ± 4.33 g/m² in the eplerenone group, with no significant between-group difference (p = 0.208). The reduction in LAVI was greater in the eplerenone group (−3.27 ± 1.58 mL/m²) compared with the irbesartan group (−2.64 ± 1.20 mL/m²), reaching statistical significance (p = 0.007). The number of antihypertensive drugs was 1.8 ± 0.8 vs 1.9 ± 0.8, p=0.164. Conclusions Echocardiographic assessment demonstrated that both irbesartan and eplerenone were associated with significant regression of left ventricular mass and improvement in diastolic function parameters over the 6-month follow-up period, with no significant difference between treatment groups in terms of LVMI reduction. Notably, eplerenone was associated with a significantly greater reduction in left atrial volume index compared with irbesartan, indicating a more pronounced effect on left atrial remodeling.