Defining diastolic heart failure and identifying effective therapies.

In this issue of JAMA, Edelmann and colleagues1 report the results of the first substantial randomized, placebo-controlled study investigating the effects of a mineralocorticoid antagonist (MRA), spironolactone, on cardiac function and exercise capacity in patients diagnosed as having heart failure with preserved ejection fraction (HFpEF). The Aldo-DHF trial included 422 patients (mean age, 67 years; 52% women) with chronic, stable symptoms attributed to heart failure, a left ventricular ejection fraction (LVEF) of at least 50%, echocardiographic evidence of LV diastolic dysfunction or atrial fibrillation, and a peak exercise oxygen consumption of 25 mL/kg/min or less during bicycle exercise. Most patients were receiving treatment for hypertension, including thiazide diuretics.1 After 12 months, patients assigned to spironolactone had lower cardiac filling pressures and LV mass, but this did not translate into improved symptoms or exercise capacity. Spironolactone was associated with a slight decline in glomerular filtration and hemoglobin concentration but not with marked hyperkalemia. Only 1 patient died during follow-up.