Effects of early initiation of mineralocorticoid receptor antagonist therapy in acute decompensated heart failure: A systematic review and meta-analysis

Abstract

Background: Acute heart failure (AHF) is a major cause of hospitalization, with high morbidity and mortality. Mineralocorticoid receptor antagonists (MRAs) improve outcomes in chronic heart failure, but their role and optimal timing in AHF remain unclear. Early initiation may enhance hemodynamic stability, yet concerns about hyperkalemia and renal dysfunction limit their use. This meta-analysis evaluates the efficacy and safety of early MRA initiation in AHF.

Methods: A systematic search of PubMed, SCOPUS, and Cochrane databases identified studies comparing early in-hospital MRA therapy plus standard care versus standard care alone in AHF patients. Pooled odds ratios (OR) with 95 % confidence intervals (CI) were calculated using a random-effects model. Primary outcomes included cardiovascular and all-cause mortality, heart failure rehospitalizations, and safety outcomes (hyperkalemia, renal deterioration, hypotension, and hypokalemia).

Results: Six studies (N = 11,039) were included. Early MRA initiation reduced cardiovascular mortality (OR 0.73, 95 % CI 0.59-0.92; p = 0.007), heart failure rehospitalizations (OR 0.56, 95 % CI 0.40-0.78; p = 0.0008), and renal deterioration (OR 0.78, 95 % CI 0.66-0.92; p = 0.003). No significant effect on all-cause mortality was observed (OR 0.88, 95 % CI 0.62-1.24; p = 0.46). A non-significant trend toward increased hyperkalemia emerged (OR 1.45, 95 % CI 0.57-3.68; p = 0.43).

Conclusion: This meta-analysis suggests that early MRA initiation in AHF improves cardiovascular outcomes and reduces rehospitalizations with an acceptable safety profile. Further large-scale randomized controlled studies are needed to confirm its long-term clinical impact.

Keywords: Acute heart failure; Early therapy; Meta-analysis; Mineralocorticoid receptor antagonists.