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Drug reduces heart failure deaths

Heart failure is emerging as a subspecialty of cardiology as we become more effective at treating heart attacks and other forms of heart disease. People with heart disease are living longer, and as they age, they may be at increased risk of their heart conditions deteriorating into heart failure.

Heart failure patients have damaged hearts that fail to pump blood adequately, usually as a result of heart attack or long-term high blood pressure. Currently about five million Americans have some degree of heart failure, according to the American Heart Association.

What is heart failure like?
Just as the severity of heart attacks varies, so does the severity of heart failure. People may experience relatively mild cases and feel discomfort only after vigorous exercise, or they may have trouble breathing and feel weak after walking across a room. The prognosis for very severe heart failure is quite poor. The mortality rate may range between 20 and 30 percent over two years and as high as 50 percent in five years.

Treatment improves
Fortunately, over the last decade, we’ve made major advances in treating the disease. ACE inhibitors have become the cornerstone of heart failure therapy along with the use of diuretics. Another, more recent, addition is use of beta blockers in appropriate patients. We used to think beta blockers were taboo when it came to treating heart failure because these drugs cause a decrease in heart function; but they are, in fact, beneficial in many patients.

Many of the drugs used to treat heart failure are effective because they interfere with the body’s somewhat counterproductive attempts to compensate for the heart’s decreased pumping ability. Because heart failure results in less blood flowing through the kidneys, the body secretes a hormone called aldosterone that causes the kidneys to retain salt and fluid in an effort to increase blood volume. Other hormones cause the heart to contract with more force and cause blood vessels to constrict, raising blood pressure.

ACE inhibitors relax blood vessels and lower blood pressure. Beta blockers reduce the heart’s tendency to beat faster. Diuretics prompt the kidneys to shed stored fluids.

Spironolactone rediscovered
Sprironolactone, which was used as a diuretic when I was in training, has fallen out of favor since the 60s and 70s because of the advent of more effective diuretics and the discovery of ACE inhibitors. The New England Journal of Medicine study shows, however, that spironolactone may be, in fact, effective in blocking aldosterone, that hormone that prompts the kidneys to retain fluid.

Subjects in the multicenter study conducted by Dr. Bertram Pitt and his colleagues at the University of Michigan were suffering from severe heart failure, the group of patients with the grimmest prognosis. When spironolactone was combined with ACE inhibitors and diuretics, the mortality rate dropped by 30 percent. Patients also reported feeling better and experienced fewer hospitalizations than those who received placebos.

Side effects
There are, however, some side effects to watch for. About 10 percent of the male subjects experienced some breast pain. The drug is similar in chemical structure to estrogen and can also cause some breast enlargement in males, a side effect I witnessed when I was a house resident many years ago.

Also spironolactone may cause a rise in the blood’s potassium level. This can be problematic since many heart failure patients may be taking a potassium supplement to counteract the depletion of this mineral when taking diuretics. It’s essential to monitor potassium levels and discontinue supplements in those patients who may begin spironolactone therapy.

The study indicates the drug could be very beneficial for patients suffering from severe heart failure, and I, in fact, would consider prescribing it for my patients with severe disease. We don’t completely understand all the biochemical mechanisms involved as yet, so we will continue to be cautious in prescribing the drug and carefully monitor patients to ensure they don’t suffer any ill effects.

I consider this to be an important finding that could be very significant for heart failure patients and those who treat them.

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Dr. Zaret is the chief of cardiovascular medicine at Yale-New Haven Hospital, medical director of the Yale-New Haven Heart Center, R.W. Berliner Professor of cardiovascular medicine at the Yale University School of Medicine and editor-in-chief of the Journal of Nuclear Cardiology.