Mineralocorticoid Receptor Antagonists in Myocardial Infarction Patients: A Systematic Review and Meta-Analysis of Randomized Trials.
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BACKGROUND: It is unclear whether routine mineralocorticoid antagonist (MRA) use benefits all post-myocardial infarction (MI) patients. OBJECTIVES: This study aims to perform a systematic review and study-level meta-analysis of randomized controlled trials comparing MRA vs no MRA in post-MI participants. METHODS: Using the intention-to-treat population, we used a fixed effect model with Peto odds ratios (ORs). Key outcomes were death and new or worsening heart failure (HF). Results were presented comparing the post-MI HF trial vs post-MI non-HF trials. RESULTS: Eleven trials, including 18,111 post-MI participants (9,064 MRA, 9,047 no MRA), were included; one trial (n = 6,642) recruited HF patients. Participants randomized to MRA compared to no MRA had a lower risk of death (OR: 0.85 [95% CI: 0.76-0.95]; I2 = 0%) and new or worsening HF (OR: 0.83 [95% CI: 0.73-0.94]; I2 = 26.8%). In the post-MI HF trial, MRA participants experienced a mortality benefit with a numerically larger risk difference (RD) (478/3,319 vs 554/3,313; OR: 0.84 [95% CI: 0.73-0.96]; RD: -2.3% [95% CI: -3.9% to -0.6%]) than in post-MI non-HF trials (219/5,745 vs 249/5,734; OR: 0.87 [95% CI: 0.72-1.05]; RD -0.5% [95% CI: -1.2% to 0.2%]; interaction P = 0.73). In the post-MI HF trial, MRA allocation decreased new or worsening HF (345/3,319 vs 391/3,313; OR: 0.87 [95% CI: 0.74-1.01]; RD: -1.4% [95% CI: -2.8% to 0.1%]) like in the post-MI non-HF trials (126/5,251 vs 167/5,241; OR: 0.75 [95% CI: 0.58-0.94]; RD: -0.8% [95% CI: -1.3% to -0.2%]; interaction P = 0.29). CONCLUSIONS: In post-MI patients, MRAs decrease the risk of all-cause mortality and new or worsening HF regardless of HF status. Numerically smaller absolute risk reductions were observed in the post-MI non-HF trials compared to the post-MI HF trial.
