Myocardial effects of aldosterone antagonism in heart failure with preserved ejection fraction

Adam K. McDiarmid, Peter P. Swoboda, Bara Erhayiem, Katrina A. Bounford, Petra Bijsterveld, Keith Tyndall, Graham J. Fent, Pankaj Garg, Laura E. Dobson, Tarique A. Musa, James R. J. Foley, Klaus K. Witte, Mark T. Kearney, John P. Greenwood, Sven Plein

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Background: Spironolactone may have prognostic benefit in selected patients with heart failure with preserved ejection fraction. This study assessed the myocardial tissue effects of spironolactone in heart failure with preserved ejection fraction. Methods and Results: A 1:1 randomized controlled study of 6 months of spironolactone versus control in heart failure with preserved ejection fraction. The primary outcome was change in myocardial extracellular volume fraction by cardiovascular magnetic resonance as a surrogate of diffuse fibrosis. Of 55 randomized patients, 40 (20 women; age, 75.2±5.9 years) completed follow-up (19 treatment, 21 control). A significant change in extracellular volume over the study period was not seen (treatment, 28.7±3.7% versus 27.7±3.4% [P=0.14]; controls, 27.6±3.4% versus 28.3±4.4% [P=0.14]); however, the rate of extracellular volume expansion was decreased by spironolactone (−1.0±2.4% versus 0.8±2.2%). Indexed left ventricular mass decreased with treatment (104.4±26.6 versus 94.0±20.6 g/m 2; P=0.001) but not in controls (101.4±29.4 versus 104.0±32.8 g/m 2; P=0.111). Extracellular mass decreased by 13.8% (15.1±4.8 versus 13.0±3.4 g/m 2; P=0.003), and cellular mass decreased by 8.3% (37.6±10.0 versus 34.3±7.9 g/m 2; P=0.001) with spironolactone, but was static in controls. Conclusions: Spironolactone did not lead to significant change in extracellular volume. However, spironolactone did decrease rate of extracellular expansion, with a decrease in the mass of both cellular and extracellular myocardial compartments. These data point to the mechanism of action of spironolactone in heart failure with preserved ejection fraction, including a direct tissue effect with a reduction in rate of myocardial fibrosis.

Original languageEnglish
Article numbere011521
JournalJournal of the American Heart Association
Issue number1
Early online date19 Dec 2019
Publication statusPublished - 7 Jan 2020


  • cardiovascular magnetic resonance
  • extracellular volume
  • heart failure
  • heart failure with preserved ejection fraction

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