The Utilization of Spironolactone in Heart Failure Patients at a Tertiary Hospital in Saudi Arabia

Introduction: Heart failure (HF) has high morbidity and mortality rates. Spironolactone has shown a 30% reduction in all-cause mortality, reduction in hospitalizations, and sudden death. However, data shows low use of spironolactone in HF patients. We aim to assess spironolactone utilization in HF reduced Ejection Fraction (HFrEF) patients and to identify the factors affecting its prescribing. Methods: A retrospective cross-sectional study of patients diagnosed with HF from January 2016 to January 2017 conducted at King Abdulaziz Medical City-Riyadh. Inclusion criteria: all adult HFrEF <40% who are eligible for spironolactone with New York Heart Association (NYHA) class II-IV. Serum creatinine should be <2.5 mg/dL in men or <2.0 mg/dL in women, or estimated glomerular filtration rate (eGFR) >30 mL/min/1.73m(2) and potassium <5.0 mEq/L. Exclusion criteria: pediatrics, end-stage renal disease, primary aldosteronism, and allergy to spironolactone. Results: We screened around 5000 HF patients, of whom 368 were included. Among 195 patients who were not on spironolactone, 121 patients were eligible to use it; however, they did not receive it. One hundred seventy-three patients were on spironolactone, of whom 30 received the drug although they did not meet the eligibility criteria. The mean age of patients on spironolactone was 61±14 and the mean age of patients not on spironolactone was 66.6±15.6. Two hundred seventy-seven patients in the study population were male. Regarding comorbidities, 265 patients were diabetic. As for laboratory findings, the mean potassium for patients on spironolactone was 4.3 mEq/L; the creatinine and eGFR for patients on spironolactone were 82 umol/L (0.9 mg/dl) and 88 mL/min/1.73m(2 )while those not on spironolactone had higher creatinine at 93 umol/L (1 mg/dl) and eGFR 80 mL/min/1.73m(2). Using multivariate regression, we found many factors affecting spironolactone utilization, including EF before spironolactone, serum creatinine, angiotensin-converting enzyme inhibitors (ACEI), angiotensin-II receptor antagonists (ARBs), furosemide, statin, and stroke. Conclusions: Spironolactone for HFrEF is underutilized. EF before spironolactone, serum creatinine, ACEI, ARBs, furosemide, statin, and stroke significantly affect spironolactone utilization. Further studies are warranted to identify barriers affecting spironolactone utilization in HF patients from prescribers' perspectives.