Role of spironolactone in heart failure should be emphasised

British Medical Journal, Sept 16, 2000 by James Mapstone, Brian Houston, Mike Gogarty

EDITOR--We welcome the article by Lonn and McKelvie on drug treatment in heart failure,[1] which is a common and important condition. The article showed how good the evidence on the subject is. We were disappointed, however, that the role of spironolactone in improving outcomes was not discussed.

A randomised controlled trial consisting of 1663 patients showed significant benefits to patients with severe heart failure and a left ventricular ejection fraction of no more than 35%.[2] These patients were already taking angiotensin converting enzyme inhibitors, loop diuretics, and, in most cases, digoxin. Ten per cent were also taking [Beta] blockers. The spironolactone group had a relative risk of death over the 24 month study period of 0.70 (95% confidence interval 0.60 to 0.82).

This equates to a number needed to treat of nine to prevent one death over the study period. The relative risk of admission to hospital was 0.65 (0.54 to 0.77; number needed to treat, 11). There was also a significant improvement in symptoms, assessed by the New York Heart Association functional class (P [is less than] 0.001).

The importance of this message is perhaps increased as representatives from the pharmaceutical industry will not be informing general practitioners of this new evidence. This is in marked contrast to what is happening with angiotensin converting enzyme inhibitors and selective [Beta] blockers.

This omission was additionally unhelpful as the article was flagged as of specific interest to general practitioners. It is important to raise awareness in primary care of this inexpensive effective intervention as initiation and monitoring are quite simple for practitioners.

James Mapstone specialist registrar public health medicine South Essex Health Authority, Brentwood CM13 3BE James.Mapstone@sessex-ha.nthames.nhs.uk

Brian Houston general practitioner Highlands Surgery, Leigh on Sea SS9 2UT

Mike Gogarty deputy director of public health South Essex Health Authority, Brentwood CM13 3BE Mike.Gogarty@sessex-ha.nthames.nhs.uk

[1] Lonn E, McKelvie R Drug treatment in heart failure, BMJ 2000;320:1188-92. (29 April.)

[2] Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999;341:709-17.