Mineralocorticoid antagonists, SGLT2 inhibitors and ACE inhibitors in heart failure
THE CONTEXT
These drug groups act through different renal and neurohumoral mechanisms and provide clinical benefits in heart failure.
Mineralocorticoid receptor antagonists
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Spironolactone and eplerenone are potassium-sparing diuretics of particular benefit in heart failure with severe left ventricular systolic dysfunction.
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They improve long-term clinical outcomes in severe heart failure or heart failure following acute myocardial infarction.
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They may cause hyperkalaemia, particularly when combined with an angiotensin-converting enzyme inhibitor.
Sodium-glucose co-transporter 2 inhibitors
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Sodium-glucose co-transporter 2 inhibitors were originally developed for type 2 diabetes mellitus. They block glucose resorption in the renal nephron, causing osmotic diuresis.
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Their use is associated with fewer heart failure hospitalisations and lower mortality, irrespective of whether diabetes is present.
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Adverse effects include increased risks of genitourinary tract infections and diabetic ketoacidosis.
Angiotensin-converting enzyme inhibitors
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Angiotensin-converting enzyme inhibitors prevent conversion of angiotensin I to angiotensin II, interrupting the neurohumoral activation characteristic of heart failure.
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They reduce peripheral vasoconstriction, sympathetic nervous system activation and aldosterone-mediated salt and water retention. They also prevent activation of the renin–angiotensin–aldosterone system caused by diuretic treatment.
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In moderate and severe heart failure, they improve effort tolerance and reduce mortality.
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After myocardial infarction, they can improve outcomes and prevent overt heart failure in patients with poor residual left ventricular function.