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Editorials |

Spironolactone for Heart Failure : Spiraling Out of Control

J. M. Geraci, MD; A. A. Knowlton, MD
Author and Funding Information

Baylor University Houston, TX ; Dr. Knowlton is with the Cardiology Section and Dr. Geraci is with the Section of General Internal Medicine and VA HSR&D Field Program, Department of Medicine, Houston Veterans Affairs Medical Center and Baylor College of Medicine.

Correspondence to: A. A. Knowlton, MD, Cardiology Research 151C, VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030-4211; e-mail: annek@bcm.tmc.edu



Chest. 2000;118(6):1522-1523. doi:10.1378/chest.118.6.1522-a
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Pharmacologic treatments improve survival and quality of life in patients with heart failure. Angiotensin-converting enzyme (ACE) inhibitors are well documented to improve both of these outcomes.1 The judicious use ofβ -blockers reduces mortality in patients with New York Heart Association (NYHA) class II and III symptoms.24 Although digoxin does not reduce all-cause mortality, it does reduce morbidity.5 More recently, a large clinical trial, the Randomized Spironolactone Evaluation Study (RALES), demonstrated that an old drug, spironolactone, administered in low doses, also improves survival.6 We worry that this result, from this single trial, has been embraced with undo enthusiasm and applied indiscriminately to patients with all classes of congestive heart failure (CHF), rather than to patients similar to those studied in the trial. In addition, we are concerned that CHF patients treated with spironolactone do not have their diuretic, β-blocker, and ACE inhibitor regimens optimized, nor are they being followed up carefully to look for electrolyte abnormalities, such as hyperkalemia and azotemia, sometimes caused by spironolactone. The simplicity of administering spironolactone therapy, compared with the work involved in titrating doses of ACE inhibitors and β-blockers, has only increased enthusiasm for this drug.

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