European Journal of Heart Failure International Expert Position Paper—Utilization, optimization, and clinical benefits of steroidal mineralocorticoid receptor antagonists in heart failure with a reduced ejection fraction

Heart failure with reduced ejection fraction (HFrEF) imposes a significant clinical burden on patients and a major economic burden on healthcare systems. In HFrEF, mineralocorticoid receptor antagonists (MRAs) constitute a cornerstone of guideline-directed medical therapy (GDMT) reducing both mortality and hospitalisation. Their use in practice remains suboptimal, largely because of physicians' concerns about adverse events, particularly hyperkalaemia, which may deprive eligible patients of benefit. Only the steroidal MRAs spironolactone and eplerenone are approved for HFrEF, and this consensus document is restricted to these agents. We summarise contemporary evidence across multiple domains related to MRA therapy in HFrEF, including pharmacoepidemiology, the role of biomarkers in predicting outcomes and response to MRA, the pathological role of aldosterone and the pharmacology and clinical efficacy of steroidal MRAs. Practical, evidence-based guidance is provided on the prevention and management of hyperkalaemia, the timing of MRA initiation, and strategies to overcome barriers to MRA use. The positioning of MRAs in current guidelines is outlined to reinforce their central role in HFrEF. The process of consensus finding was started in April 2025 with a core group by online conference. We searched PubMed with the terms "MRA, eplerenone and heart failure with reduced ejection fraction". Articles published in English with no date restriction were considered. The final manuscript passed two rounds of final approval by all authors. As a result, this consensus statement advocates proactive, evidence-based approaches to optimise MRA use to improve outcomes. These recommendations aim to mitigate the persistent underuse of MRAs in clinical practice.

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Publication Details

Journal
European Journal of Heart Failure
Published
2026-04-02
DOI
https://doi.org/10.1093/ejhf/xuag106
Citations
1
Primary Topic
Hormonal Regulation and Hypertension
Type
article
Field-Weighted Citation Impact
19.16
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article

European Journal of Heart Failure International Expert Position Paper—Utilization, optimization, and clinical benefits of steroidal mineralocorticoid receptor antagonists in heart failure with a reduced ejection fraction

J. Abdullakutty, Udo Bavendiek, Giuseppe Rosano, Lei Zhang et al.
1 citations
European Journal of Heart Failure
Hormonal Regulation and Hypertension
19.16
article

European Journal of Heart Failure International Expert Position Paper—Utilization, optimization, and clinical benefits of steroidal mineralocorticoid receptor antagonists in heart failure with a reduced ejection fraction

J. Abdullakutty, Udo Bavendiek, Giuseppe Rosano, Lei Zhang, Thorsten Kessler, Gianluigi Savarese, Antoni Bayes-genis A, Amina Rakisheva, Nikolaus Marx, Samuel Tobias Sossalla, Faiez M. Zannad, Jagdish Hiremath, K. Tsioufis, Philipp Markwirth, Jan Biegus, Shelley R. Zieroth, Arindam Pande, Teresa McDonagh, Girish Navsundi, Kuntal Bhattacharyya, Dilip Kumar, K Sliwa, N Sato, J Bauersachs, Mert Tokcan, Yuhui Zhang, Pardeep Jhund, Michael Böhm, Mark Petrie, B Somaraju, J Ezhilan, Stefan Störk, Piotr Ponikowski, Rahul Gupta, Joao P Ferreira, Nicolas Girerd, Kamal Sharma
article en
1 citations

Abstract

Heart failure with reduced ejection fraction (HFrEF) imposes a significant clinical burden on patients and a major economic burden on healthcare systems. In HFrEF, mineralocorticoid receptor antagonists (MRAs) constitute a cornerstone of guideline-directed medical therapy (GDMT) reducing both mortality and hospitalisation. Their use in practice remains suboptimal, largely because of physicians' concerns about adverse events, particularly hyperkalaemia, which may deprive eligible patients of benefit. Only the steroidal MRAs spironolactone and eplerenone are approved for HFrEF, and this consensus document is restricted to these agents. We summarise contemporary evidence across multiple domains related to MRA therapy in HFrEF, including pharmacoepidemiology, the role of biomarkers in predicting outcomes and response to MRA, the pathological role of aldosterone and the pharmacology and clinical efficacy of steroidal MRAs. Practical, evidence-based guidance is provided on the prevention and management of hyperkalaemia, the timing of MRA initiation, and strategies to overcome barriers to MRA use. The positioning of MRAs in current guidelines is outlined to reinforce their central role in HFrEF. The process of consensus finding was started in April 2025 with a core group by online conference. We searched PubMed with the terms "MRA, eplerenone and heart failure with reduced ejection fraction". Articles published in English with no date restriction were considered. The final manuscript passed two rounds of final approval by all authors. As a result, this consensus statement advocates proactive, evidence-based approaches to optimise MRA use to improve outcomes. These recommendations aim to mitigate the persistent underuse of MRAs in clinical practice.

European Journal of Heart Failure
Apollo Hospitals (IN), University of Cape Town (ZA), Baylor College of Medicine (US), Chinese Academy of Medical Sciences & Peking Union Medical College (CN), Justus-Liebig-Universität Gießen (DE), Ruby Hall Clinic (IN), Madras Medical Mission (IN), Karolinska Institutet (SE), Narayana Health (IN), Kawaguchi Junior College (JP), San Raffaele University of Rome (IT), Ahmedabad Civil Hospital (IN), Medizinische Hochschule Hannover (DE), University of Mississippi (US), Wroclaw Medical University (PL), Lourdes Hospital (IN), Universitätsklinikum des Saarlandes (DE), Baylor Medical Center at Garland (US), Universitätsklinikum Aachen (DE), Kazakh Institute of Oncology and Radiology (KZ), Universitätsklinikum Würzburg (DE), Apollo Hospitals (IN), Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol (ES), Noguchi Hospital (JP), Asha Hospital (IN), King's College Hospital (GB), Hospital Universitari Germans Trias i Pujol (ES), Cardio-Pulmonary Institute (DE), Fu Wai Hospital (CN), Manipal Hospital (IN), Hippocration General Hospital (GR), French Clinical Research Infrastructure Network (FR), University of Manitoba (CA), University of Glasgow (GB), The University of Winnipeg (CA), RWTH Aachen University (DE), Saarland University (DE)
Good health and well-being
Openalex Percentile: Top 1%
Hormonal Regulation and Hypertension
19.16
DOISourceOpenAlex
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