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Сообщение от Dr.

Я пока стою за верошпирон

Тем временем в АНА/АСС, похоже, антагонисты альдостероновых рецепторов вызывают все меньше энтузиазма и все больше боязни гиперкалиемии (цитирую по ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult):

RECOMMENDATIONS
Class I
Addition of an aldosterone antagonist is reasonable in
selected patients with moderately severe to severe
symptoms of HF and reduced LVEF who can be carefully
monitored for preserved renal function and normal
potassium concentration. Creatinine should be
less than or equal to 2.5 mg/dL in men or less than or
equal to 2.0 mg/dL in women and potassium should be
less than 5.0 mEq/L. Under circumstances where
monitoring for hyperkalemia or renal dysfunction is
not anticipated to be feasible, the risks may outweigh
the benefits of aldosterone antagonists. (Level of
Evidence: B)

Recommendations Concerning Aldosterone
Antagonists.
The addition of low-dose aldosterone antagonists should be
considered in carefully selected patients with moderately
severe or severe HF symptoms and recent decompensation or
with LV dysfunction early after MI. These recommendations
are based on the strong data demonstrating reduced death
and rehospitalization in 2 clinical trial populations (98,141).
The entry criteria for these trials describe a broader population than was actually enrolled, such that the favorable efficacy/ toxicity ratio may not be as applicable to patients at the margins of trial eligibility. For both of these major trials, patients were excluded for a serum creatinine level in excess of 2.5 mg per dL, but few patients were actually enrolled with serum creatinine levels over 1.5 mg per dL. In the trial of patients after MI, there was a significant interaction between serum creatinine and benefit of eplerenone. The average serum creatinine of enrolled patients was 1.1 mg per dL, above which there was no demonstrable benefit for survival.To minimize the risk of life-threatening hyperkalemia in patients with low LVEF and symptoms of HF, patients should have initial serum creatinine less than 2.0 to 2.5 mg per dL without recent worsening and serum potassium less than 5.0 mEq per dL without a history of severe hyperkalemia.
In view of the consistency of evidence for patients
with low LVEF early after MI and patients with recent
decompensation and severe symptoms, it may be reasonable to consider addition of aldosterone antagonists to loop diuretics for some patients with mild to moderate symptoms of HF; however, the Writing Committee strongly believes that there are insufficient data or experience to provide a specific or strong recommendation. Because the safety and efficacy of aldosterone antagonist therapy has not been shown in the absence of loop diuretic therapy, it is not currently recommended that such therapy be given without other concomitant diuretic therapy in chronic HF. Although 17% of patients in the CHARM add-on trial were receiving spironolactone, the safety of the combination of ACEIs, ARBs, and aldosterone antagonists has not been explored adequately, and this combination cannot be recommended.