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Evaluating the efficacy of mineralocorticoid receptor antagonism in patients with STEMI without heart failure

Benjamin M. Scirica
DOI: http://dx.doi.org/10.1093/eurheartj/ehu191 2276-2278 First published online: 30 April 2014

This editorial refers to ‘Early eplerenone treatment in patients with acute ST-elevation myocardial infarction without heart failure: the randomized double-blind REMINDER study’, by G. Montalescot et al., on page 2295

There are three key elements to any clinical trial: study population, study intervention, and outcome. The REMINDER study1 reported by Montalescot et al., is worth considering in detail because of how the investigators ultimately decided these three questions: the choice of ST-segment elevation myocardial infarction (STEMI) patients without heart failure as the population of interest, the selection of the mineralocorticoid receptor antagonist (MRA) eplerenone as the intervention, and the use of natriuretic peptides as the principal measurement of efficacy.

To summarize, the REMINDER study randomized 1012 patients presenting with STEMI but no evidence of heart failure to eplerenone or placebo within 24 h of symptoms, and followed them for ∼10 months. Treatment with eplerenone significantly reduced the risk of a composite endpoint of an elevated natriuretic peptide or an extended list of clinical events by >40% compared with placebo, mostly driven by lower levels of natriuretic peptides at least 1 month after randomization.

ST-segment elevation myocardial infarction without heart failure

Most studies evaluating therapy to improve remodelling focus only on patients with large, anterior STEMI or an ejection fraction <40%, which is logical given that these patients are at the highest risk of subsequent heart failure, arrhythmic events, and death. However, with more rapid reperfusion, they currently account for a small proportion of patients presenting with MI. In > 77 000 patients with STEMI enrolled in one contemporary registry, only 12% presented with heart failure and just 3.6% developed heart failure after admission,2 a substantially lower number than earlier cohorts.3 Moreover, only 20% of patients with STEMI and no heart failure in this registry had an ejection fraction <40%2 (Figure 1). Studies …

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