The new guidelines state that the combination of “an ACE inhibitor [or angiotensin receptor blocker (ARB)], a beta-blocker, and an MRA, are fundamentally important in modifying the course of systolic heart failure and should at least be considered in every patient”.
This update provides welcome guidance to UK clinicians as it builds upon existing NICE guidance developed before the EMPHASIS-HF trial results were published.
Results of the EMPHASIS-HF trial showed that eplerenone (Inspra, Pfizer) reduces the risk of cardiovascular death or heart failure hospitalisation by more than a third compared to placebo in heart failure patients already receiving current standard therapy (RRR = 37%, p<0.001; ARR = 7.6%, p<0.001). These results were achieved against a quality of background therapy seldom seen in day to day clinical practice – 94% of patients in the eplerenone arm were also receiving an ACE inhibitor and over 86% were receiving a beta-blocker – highlighting the additive benefit of MRAs over standard therapy.
“The inclusion of eplerenone and mineralocorticoid receptor antagonists in the latest ESC guidelines is a significant step in making these life saving and cost effective treatments available to patients that need them,” said Martin Cowie, professor of Cardiology at Imperial College and consultant cardiologist at the Royal Brompton Hospital, London, UK. “Eplerenone should be offered to all eligible patients who continue to exhibit symptoms as it has been shown not only to save lives but, importantly, help keep patients out of hospital.”
Eplerenone has also been shown to reduce the likelihood of patients being admitted to hospital (due to heart failure) by over 40% (RRR 42%, p<0.001; ARR 6.8%, p<0.001). Hospitalisation due to HF is commonplace and every heart failure emergency admission costs at least £2,400.
Health economic analysis of eplerenone in patients with chronic heart failure (NYHA class II) have shown that eplerenone as an add-on to standard optimal therapy is highly cost-effective compared to standard therapy alone, with an incremental cost per Quality Adjusted Life Year (QALY) gained of £3,534, well below the lower £20,000 threshold typically viewed by NICE as representing good value for money.
Eplerenone has recently been approved in the UK to reduce the risk of cardiovascular mortality and morbidity in adult patients with NYHA class II (chronic) heart failure and left ventricular systolic dysfunction (left ventricular ejection fraction ≤30%), in addition to standard optimal therapy. It is also indicated to treat patients with heart failure and left ventricular ejection fraction ≤ 40%, after recent myocardial infarction again, alongside standard therapy.