Aldosterone Antagonists

A principal feature of CHF is marked activation of the renin-angiotensin-aldosterone system. In heart failure patients, plasma aldosterone concentrations may increase to as high as 20 times the normal level. Aldosterone has a range of biological effects beyond salt retention (Table 33-2), and antagonism of aldosterone's actions may be beneficial in patients with heart failure. The beneficial effects of spironolactone on mortality appear to be additive to those of ACE inhibitors and b receptor antagonists in patients with symptomatic heart failure; the use of spironolactone should be considered in patients with NYHA Class III and IV heart failure. Caution should be exercised when significant renal impairment is present. Treatment is initiated at a dose of 12.5 or 25 mg daily, as higher doses may lead to hyperkalemia, particularly in patients receiving an ACE inhibitor. Serum K+ levels and electrolytes should be checked after initiation of treatment, and vigilance is warranted for potential drug interactions and medical disorders that may elevate serum K+ concentration ( e.g., potassium supplements, ACE inhibitors, and worsening renal function).

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