A simple measure of waist circumference could identify chronic heart failure patients who would benefit most from mineralocorticoid receptor antagonists, according to a review published July 25 in JAMA Cardiology.
Awareness of this association is important in routine clinical practice because primary care physicians only prescribe this class of drugs to between 10 and 25 percent of eligible patients, noted review author Milton Packer, MD. This is despite strong clinical evidence that spironolactone and eplerenone are effective in treating this population.
Packer pointed out the EMPHASIS-HF trial showed a reduction in the combined endpoint of heart failure hospitalization plus cardiovascular death in the overall study group, but the treatment drug was most effective for patients with abdominal obesity. Specifically, eplerenone reduced the risk of meeting that endpoint by 52 percent for those with a large waist circumference and by only 22 percent in individuals who weren’t obese. Also, patients with abdominal obesity appeared to tolerate the treatment better.
Another trial of patients with heart failure with preserved ejection fraction showed patients most likely to have abdominal obesity—demonstrated by their level of natriuretic peptides—experienced the greatest benefit from spironolactone.
“Although these analyses are post hoc, their concordance and strong biological foundation suggests that abdominal obesity may identify patients who respond most favorably to mineralocorticoid receptor antagonism,” wrote Packer, with the Baylor Heart and Vascular Institute in Dallas. “Given the easy availability of its measurement, targeting patients with an increased waist circumference could enhance the adoption of these important drugs for the treatment of chronic heart failure in clinical practice.”
Packer emphasized that measuring waist circumference is easier and more likely to be widely adopted than ordering a serum biomarker test. In this case, it is also more informative than calculating body mass index because excess fat in the belly is more indicative of circulating levels of aldosterone, which play a role in the development of heart failure.
“The strong association between central obesity and aldosterone explains the sodium retention, plasma volume expansion, and increased cardiac volumes seen in obese patients with heart failure and the cardiac fibrosis and decreased ventricular distensibility seen in obese patients with heart failure and a preserved ejection fraction,” Packer wrote.
“If confirmed by additional studies, abdominal obesity may prove to be useful in facilitating the appropriate prescribing of spironolactone and eplerenone in patients with chronic heart failure and identifying patients most likely to benefit from and tolerate these drugs.”
Daniel joined TriMed’s Chicago editorial team in 2017 as a Cardiovascular Business writer. He previously worked as a writer for daily newspapers in North Dakota and Indiana.