Aldosterone Blockade in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis

Abstract

Background. A comprehensive evaluation of the benefits of mineralocorticoid receptor antagonists (MRA) in acute myocardial infarction (AMI) patients is lacking. Objective. To summarize the evidence on the efficacy and safety of MRA in patients admitted for AMI. Methods. Articles were identified through PubMed, Embase, Cochrane Library, Ovid (Medline1946-2021), and ClinicalTrials.gov databases from their inception to December 31, 2020. Results. 15 articles with a total of 11,861 patients were included. MRA reduced the risk of all-cause mortality by 16% (relative ratio (RR): 0.84; 95% confidence interval (CI) (0.76, 0.94); $P=0.002$ ) and the incidence of cardiovascular adverse events by 12% (RR: 0.88, 95% CI (0.83, 0.93), $P<0.00001$ ) in post-AMI patients, and further analysis demonstrated that early administration of MRA within 7 days after AMI resulted in a greater reduction in all-cause mortality (RR: 0.72, 95% CI (0.61, 0.85), $P<0.0001$ ). Subgroup analyses showed that post-STEMI patients without left ventricular systolic dysfunction (LVSD) treated with MRA had a 36% reduction in all-cause mortality (RR: 0.64, 95% CI (0.46, 0.89), $P=0.007$ ) and a 22% reduction in cardiovascular adverse events (RR: 0.78, 95% CI (0.67, 0.91), $P=0.002$ ). Meanwhile, post-STEMI patients without LVSD treated with MRA get significant improvements in left ventricular ejection fraction (mean difference (MD): 2.69, 95% CI (2.44, 2.93), $P<0.00001$ ), left ventricular end-systolic index (MD: -4.52 ml/m2, 95% CI (-8.21, -0.83), $P=0.02$ ), and left ventricular end-diastolic diameter (MD: -0.11 cm, 95% CI (-0.22, 0.00), $P=0.05$ ). The corresponding RR were 1.72 (95% CI (1.43, 2.07), $P<0.00001$ ) for considered common adverse events (hyperkalemia, gynecomastia, and renal dysfunction). Conclusions. Our findings suggest that MRA treatment reduces all-cause mortality and cardiovascular adverse events in post-AMI patients, which is more significant in patients after STEMI without LVSD. In addition, MRA treatment may exert beneficial effects on the reversal of cardiac remodeling in patients after STEMI without LVSD.