Spironolactone metabolite concentrations in decompensated heart failure: insights from the ATHENA-HF trial

Aims In Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure (ATHENA-HF), high-dose spironolactone (100 mg daily) did not improve efficacy endpoints over usual care [placebo or continued low-dose spironolactone (25 mg daily) in patients already receiving spironolactone] in the treatment of acute heart failure (HF). We hypothesized that low concentrations of the long-acting active metabolites of spironolactone [canrenone and 7 alpha-thiomethylspironolactone (7 alpha-TMS)] in the high-dose group could have contributed to these neutral results. Methods and results In patients randomized to high-dose spironolactone not previously treated with spironolactone (high-dose-naive, n = 112), concentrations of canrenone and 7 alpha-TMS increased at 48 and 96 h compared to baseline, and between 48 and 96 h (all P < 0.005), indicating that steady-state concentrations had not been reached by 48 h. In patients previously on low-dose, high-dose spironolactone (high-dose-previous, n = 37), concentrations of canrenone increased at 48 and 96 h compared to baseline (both P < 0.0005), with a marginal increase between 48 and 96 h (P = 0.0507). At 48 h, both high-dose groups had higher concentrations of both metabolites than the low-dose spironolactone group (P < 0.0001). Moreover, concentrations of both metabolites were higher in high-dose-previous vs. high-dose-naive patients (P < 0.01), indicating that previous spironolactone use was significant, and that steady-state has not been reached in high-dose-naive patients at 48 h. We found limited and inconsistent evidence of correlation between metabolite concentrations and endpoints. Conclusions Lower-than-anticipated concentrations of spironolactone active metabolites were observed for at least 48 h in the high-dose spironolactone group and may have contributed to the absence of pharmacological effects of spironolactone in the ATHENA-HF trial.