Aldosterone Antagonists in Patients With Heart Failure

To the Editor: In their report on the use of aldosterone antagonists in HF, Dr Albert and colleagues¹ observed that being African American was an independent predictor of aldosterone antagonist prescription. This is somewhat surprising considering the limited evidence for the efficacy of aldosterone antagonists in African American individuals with HF.

The representation of African American individuals in the 2 survival studies with aldosterone antagonists was small, less than 1% in the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS)² and 13% in the Randomized Aldactone Evaluation Study (RALES).³ In the latter, only 11% of all patients received β-blockers. Furthermore, a retrospective analysis of the African American Heart Failure Trial (A-HeFT) demonstrated lack of benefit of spironolactone in African American patients with HF who were not concomitantly receiving the combination of hydralazine and isosorbide dinitrate.⁴ There should be a focus on recommendations based on proven effectiveness in improving outcomes.