Mineralocorticoid receptor antagonists in elderly patients with heart failure: a systematic review and meta-analysis

Background: Mineralocorticoid receptor antagonists (MRAs) improve outcomes in several populations of patients with heart failure (HF), but there has been no systematic review of MRAs in older patients. Objectives: Systematic review and meta-analysis of the efficacy and safety of MRA treatment in elderly HF patients. Data Sources: Trials were identified through a literature search until 24 January 2015. Study Selection: Randomised controlled trials (RCTs) of MRAs in patients with HF and/or left ventricular systolic dysfunction aged ≥65 years, with subgroup analysis of patients ≥65 years or with mean participant age ≥70 years. Data Extraction and Synthesis: Efficacy outcomes were mortality, hospitalisation for cardiovascular causes, symptom status or functional capacity. Safety outcomes were hyperkalaemia and renal dysfunction. Data were analysed using relative risk ratios with 95% confidence intervals. Relative risk ratios were pooled where more than three estimates were available. Results: Seven RCTs were included (total n = 8,638). Three RCTs in HF with reduced ejection fraction (HEFREF) reported overall benefit from MRA therapy with no significant treatment interaction for age; the effects of MRAs on mortality in patients ≥75 years displayed marked inter-study heterogeneity. In four RCTs of HF with preserved ejection fraction (HEFPEF), MRA treatment had no significant effect on any efficacy outcome. Conclusion: MRAs improve clinical outcomes in selected cohorts of older patients with HEFREF but not HEFPEF. In patients ≥75 years with HEFREF, the effect of MRA treatment on overall mortality is uncertain. Further study is required in subgroups of elderly patients with both HEFREF and HEFPEF.