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This editorial refers to ‘Mineralocorticoid receptor antagonists and atrial fibrillation: a meta-analysis of clinical trials’, by
A. Oraii et al., https://doi.org/10.1093/eurheartj/ehad811.
Graphical Abstract
MRA
Reduction of CV death and HFH Reduction of AF events, new and recurrent Reduction of CV death and HFH
(RR 0.84; 95% CI: 0.75–0.93) (RR 0.76; 95% CI: 0.67–0.87) (RR 0.81; 95% CI: 0.67–0.98)
Landmark achievements, current evidence and future challenges in the research of mineralocorticoid receptor antagonist use at different stages of
cardiovascular disease.
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
* Corresponding author. Tel: +49 30 450653731, Fax: +49 30 4507553731, Email: frank.edelmann@dhzc-charite.de
© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
2 Editorial
Since mineralocorticoids were discovered as key endocrine regulators In the second step of the analysis, Oraii et al. assessed the effect of
of water and electrolyte homeostasis and blood pressure control, fur- MRA treatment on AF events, including new-onset and recurrent AF.
ther research has revealed their role in fibrotic myocardial and vascular They found an overall relative risk reduction of .76 (95% CI .67–.87)
remodelling. Mineralocorticoid receptor antagonists (MRAs) have been and absolute risk reduction of 1.2% for MRA vs. placebo or usual
investigated in various clinical trials, initially focusing on the treatment of care in patients with CV risk factors or established CV disease. Based
heart failure with reduced left ventricular ejection fraction (HFrEF), on the risk of bias due to potential differences in AF assessment be-
while heart failure with preserved ejection fraction (HFpEF) has been tween trials, the authors considered these findings to be moderate-
receiving more and more attention in the past decades. Demonstrating quality evidence. Subgroup and sensitivity analyses did not suggest
with left atrial size.13 Whether there is an association of fibrosis markers References
with hospitalizations or mortality in AF patients remains unknown. 1. Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. The effect of spirono-
Recent and ongoing trials provide a promising outlook on imple- lactone on morbidity and mortality in patients with severe heart failure. Randomized
menting MRA therapy in patients at high risk of HF who often do aldactone evaluation study investigators. N Engl J Med 1999;341:709–17. https://doi.
not tolerate MRAs due to hyperkalaemia, especially patients with org/10.1056/NEJM199909023411001
2. Tsai CT, Chiang FT, Tseng CD, Hwang J-J, Kuo K-T, Wu C-K, et al. Increased expression
type 2 diabetes and/or chronic kidney disease (CKD). Post-hoc ana- of mineralocorticoid receptor in human atrial fibrillation and a cellular model of atrial
lyses of recent sodium–glucose co-transporter 2 inhibitor (SGLT2i) fibrillation. J Am Coll Cardiol 2010;55:758–70. https://doi.org/10.1016/j.jacc.2009.09.045
trials showed a reduced rate of hyperkalaemia in high-risk patients 3. Lavall D, Selzer C, Schuster P, Lenski M, Adam O, Schäfers H-J, et al. The mineralocor-