OBJECTIVES This study sought to assess the effect of MRA treatment (vs. placebo) in older patients (≥75 years of age) compared with younger patients (<75 years of age) with heart failure (HF). BACKGROUND Mineralocorticoid receptor antagonists (MRAs) have been shown to reduce morbidity and mortality in patients with HF with reduced ejection fraction (HFrEF) and in a subset of patients with HF with preserved EF (HFpEF). Notwithstanding, MRAs are underused, especially in the elderly. Pooling the individual patient data (IPD) provided more statistical power with which to assess the efficacy and safety of MRA treatment in this subpopulation. METHODS An IPD meta-analysis was performed using Cox proportional hazards models stratified by trial. A total of 1,756 patients (853 randomized to placebo and 903 to MRA) ≥75 years of age, along with 4,411 patients (2,242 randomized to placebo and 2,169 to MRA) <75 years of age were included. The primary outcome was a composite of death from cardiovascular causes or hospitalization for HF. RESULTS The treatment groups were well balanced. Patients ≥75 years of age or older and those 80 years of age, 61% were male, 30% had diabetes, and the mean estimated glomerular filtration rate 59 ml/min. The primary outcome occurred in 331 patients (38.8%) in the placebo group versus 281 (31.1%) in the MRA group (hazard ratio: 0.74; 95% confidence interval: 0.63 to 0.86; p < 0.001; and the heterogeneity p value [heterogeneity p = Cochran's Q p value of treatment effect by study interaction] was 0.52). Cardiovascular death and all-cause death were also reduced by MRAs without significant between-trial or age (younger vs. older) heterogeneity. Worsening renal function and hyperkalemia occurred more frequently in patients taking MRAs (vs. placebo). Compared to younger patients, worsening renal function (but not hyperkalemia) was found more frequently in the elderly. CONCLUSIONS MRAs reduced morbidity and mortality in elderly patients with HF, a beneficial effect that is more marked in patients with HFrEF but homogenous across HFrEF and HFpEF. Implementation of measures that increase MRA treatment in this population are warranted.

中文翻译：

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老年HF患者的MRA：RALES，EMPHASIS-HF和TOPCAT的患者数据荟萃分析。

目的本研究旨在评估MRA治疗（与安慰剂相比）对心力衰竭（HF）的老年患者（≥75岁）与年轻患者（<75岁）的影响。背景技术已显示盐皮质激素受体拮抗剂（MRA）可以降低射血分数降低的HF患者（HFrEF）和部分EF保留的HF患者（HFpEF）的发病率和死亡率。尽管如此，MRA仍未得到充分利用，尤其是在老年人中。合并单个患者数据（IPD）提供了更多的统计能力，可用来评估该亚人群中MRA治疗的疗效和安全性。方法采用试验分层的Cox比例风险模型进行IPD荟萃分析。年龄≥75岁的1,756名患者（其中853名被随机分配给安慰剂，903名被分配给MRA），以及4，年龄小于75岁的411例患者（随机分配给安慰剂的2,242例，接受MRA的2169例）。主要结局是因心血管原因死亡或因心衰住院所致。结果治疗组平衡良好。≥75岁或以上的患者和80岁以上的患者，男性61％，糖尿病30％，平均肾小球滤过率估计为59 ml / min。安慰剂组的主要结局发生在331例患者中（38.8％），而MRA组的发生率是281例（31.1％）（危险比：0.74； 95％置信区间：0.63至0.86； p <0.001；异质性p值[异质性p =通过研究相互作用获得的Cochran's Q p值]为0.52）。没有明显的试验间或年龄（年轻人与老年人）异质性的MRA还可减少心血管死亡和全因死亡。服用MRA的患者（相对于安慰剂）更经常出现肾功能恶化和高钾血症。与年轻患者相比，老年人中肾功能恶化（而非高钾血症）的发生频率更高。结论MRA降低了老​​年HF患者的发病率和死亡率，这种有益作用在HFrEF患者中更为明显，但在HFrEF和HFpEF之间是同质的。有必要采取措施增加该人群的MRA治疗。这种有益效果在HFrEF患者中更为明显，但在HFrEF和HFpEF之间是同质的。有必要采取措施增加该人群的MRA治疗。这种有益效果在HFrEF患者中更为明显，但在HFrEF和HFpEF之间是同质的。有必要采取措施增加该人群的MRA治疗。