Eplerenone Insights on Aldosterone Dynamics: EPHESUS Revisited | JACC Baran

Hosts Mitsuaki Sawano, MD, Kentaro Ejiri, MD, and Satoshi Shoji, MD, welcome Dr. Masatake Kobayashi of Tokyo Medical University to explore the interaction between aldosterone and mineralocorticoid receptor antagonists (MRAs) in a post hoc analysis of the EPHESUS trial. Dr. Kobayashi reviews findings from a cohort of post–myocardial infarction patients with left ventricular dysfunction or heart failure in whom aldosterone levels were measured. In the placebo group, higher baseline aldosterone or an increase over one month was associated with cardiovascular death or heart failure hospitalization, whereas these associations were not observed in the eplerenone group. The analysis offers descriptive evidence on how MRA therapy may modify the relationship between aldosterone and outcomes, even in a population with relatively low aldosterone levels compared to prior studies. The discussion extends to implications for GDMT optimization in Japan, as well as distinctions among spironolactone, eplerenone, and the emerging non-steroidal MRA, finerenone.