{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T15:15:24Z","timestamp":1787584524321,"version":"build-2736575974"},"reference-count":38,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2022,9,1]],"date-time":"2022-09-01T00:00:00Z","timestamp":1661990400000},"content-version":"unspecified","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Open Heart"],"accepted":{"date-parts":[[2022,8,9]]},"published-print":{"date-parts":[[2022,9]]},"abstract":"<jats:sec>\n                  <jats:title>Introduction<\/jats:title>\n                  <jats:p>Mineralocorticoid receptor antagonists (MRAs) reduce mortality and morbidity in patients with heart failure and reduced ejection fraction (HFrEF), but are largely underused. We evaluated the frequency, motives, predictors and outcomes of MRA discontinuation in a real-world heart failure population.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods and results<\/jats:title>\n                  <jats:p>This was a single-centre, retrospective cohort study where medical record-based data were collected on patients with HFrEF between 2010 and 2018. In the final analysis, 572 patients were included that comprised the continued MRA group (n=275) and the discontinued MRA group (n=297). Patients that discontinued MRA were older, had a higher comorbidity index and a lower index estimated glomerular filtration rate (eGFR). Predictors of MRA discontinuations were increased S-potassium, lower eGFR, lower systolic blood pressure, higher frequency of comorbidities and a higher left ventricular ejection fraction. The most common reason for MRA discontinuation was renal dysfunction (n=97, 33%) with 59% of these having an eGFR &lt;30\u2009mL\/min\/1.73m<jats:sup>2<\/jats:sup>, and elevated S-potassium (n=71, 24%) with 32% of these having an S-potassium &gt;5.5\u2009mmol\/L. Discontinuation of MRA increased the adjusted risk of all-cause mortality (HR 1.48; 95%\u2009CI 1.07 to 2.05; p=0.019).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Half of all patients with HFrEF initiated on MRA discontinued the treatment. A substantial number of patients discontinued MRA without meeting the guideline-recommended levels of eGFR and S-potassium where mild to moderate hyperkalaemia seems to be the most decisive predictor. Further, MRA discontinuation was associated with increased adjusted risk of all-cause mortality.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/openhrt-2022-002022","type":"journal-article","created":{"date-parts":[[2022,9,1]],"date-time":"2022-09-01T11:55:46Z","timestamp":1662033346000},"page":"e002022","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":15,"title":["Motives, frequency, predictors and outcomes of MRA discontinuation in a real-world heart failure population"],"prefix":"10.1136","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9319-0242","authenticated-orcid":false,"given":"Anna","family":"Jonsson Holmdahl","sequence":"first","affiliation":[{"name":"Department of Public Health and Clinical Medicine, Ume\u00e5 universitet Medicinska fakulteten, Umea, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gustav","family":"Wessberg","sequence":"additional","affiliation":[{"name":"Department of Public Health and Clinical Medicine, Ume\u00e5 universitet Medicinska fakulteten, Umea, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Helena","family":"Norberg","sequence":"additional","affiliation":[{"name":"Department of Integrative Medical Biology, Ume\u00e5 universitet Medicinska fakulteten, Umea, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrian","family":"S\u00f6derstr\u00f6m","sequence":"additional","affiliation":[{"name":"Department of Public Health and Clinical Medicine, Ume\u00e5 universitet Medicinska fakulteten, Umea, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fredrik","family":"Valham","sequence":"additional","affiliation":[{"name":"Department of Public Health and Clinical Medicine, Ume\u00e5 universitet Medicinska fakulteten, Umea, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ellinor","family":"Bergdahl","sequence":"additional","affiliation":[{"name":"Department of Public Health and Clinical Medicine, Ume\u00e5 universitet Medicinska fakulteten, Umea, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5756-7791","authenticated-orcid":false,"given":"Krister","family":"Lindmark","sequence":"additional","affiliation":[{"name":"Department of Public Health and Clinical Medicine, Ume\u00e5 universitet Medicinska fakulteten, Umea, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2022,9,1]]},"reference":[{"key":"2025081710210276000_9.2.e002022.1","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199909023411001"},{"key":"2025081710210276000_9.2.e002022.2","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1009492"},{"key":"2025081710210276000_9.2.e002022.3","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa030207"},{"key":"2025081710210276000_9.2.e002022.4","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehab368"},{"key":"2025081710210276000_9.2.e002022.5","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2013.05.019"},{"key":"2025081710210276000_9.2.e002022.6","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1002\/ejhf.496","article-title":"Use of evidence-based therapy and survival in heart failure in Sweden 2003-2012","volume":"18","author":"Thorvaldsen","year":"2016","journal-title":"Eur J Heart Fail"},{"key":"2025081710210276000_9.2.e002022.7","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2018.04.070"},{"key":"2025081710210276000_9.2.e002022.8","doi-asserted-by":"crossref","first-page":"247","DOI":"10.1007\/s00228-018-2574-6","article-title":"Decrease in loop diuretic treatment from 2005 to 2014 in Swedish real-life patients with chronic heart failure","volume":"75","author":"Par\u00e9n","year":"2019","journal-title":"Eur J Clin Pharmacol"},{"key":"2025081710210276000_9.2.e002022.9","article-title":"Evaluation of the usage and dosing of guideline-directed medical therapy for heart failure with reduced ejection fraction patients in clinical practice","volume":"8971900211004840","author":"Smith","year":"2021","journal-title":"J Pharm Pract"},{"key":"2025081710210276000_9.2.e002022.10","doi-asserted-by":"crossref","DOI":"10.1111\/1755-5922.12459","article-title":"Obstacles to mineralocorticoid receptor antagonists in a community-based heart failure population","volume":"36","author":"Jonsson","year":"2018","journal-title":"Cardiovasc Ther"},{"key":"2025081710210276000_9.2.e002022.11","doi-asserted-by":"crossref","first-page":"1834","DOI":"10.1007\/s00134-012-2636-7","article-title":"Association between hyperkalemia at critical care initiation and mortality","volume":"38","author":"McMahon","year":"2012","journal-title":"Intensive Care Med"},{"key":"2025081710210276000_9.2.e002022.12","doi-asserted-by":"publisher","DOI":"10.1161\/JAHA.118.008912"},{"key":"2025081710210276000_9.2.e002022.13","doi-asserted-by":"publisher","DOI":"10.1016\/S0735-1097(20)33463-X"},{"key":"2025081710210276000_9.2.e002022.14","doi-asserted-by":"crossref","first-page":"231","DOI":"10.2147\/CLEP.S170873","article-title":"Epidemiology of heart failure and trends in diagnostic work-up: a retrospective, population-based cohort study in Sweden","volume":"11","author":"Lindmark","year":"2019","journal-title":"Clin Epidemiol"},{"key":"2025081710210276000_9.2.e002022.15","doi-asserted-by":"publisher","DOI":"10.1136\/openhrt-2016-000568"},{"key":"2025081710210276000_9.2.e002022.16","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(17)32520-5"},{"key":"2025081710210276000_9.2.e002022.17","doi-asserted-by":"crossref","first-page":"1217","DOI":"10.1002\/ejhf.1199","article-title":"Incidence, predictors and clinical management of hyperkalaemia in new users of mineralocorticoid receptor antagonists","volume":"20","author":"Trevisan","year":"2018","journal-title":"Eur J Heart Fail"},{"key":"2025081710210276000_9.2.e002022.18","doi-asserted-by":"publisher","DOI":"10.1177\/1049732305276687"},{"key":"2025081710210276000_9.2.e002022.19","doi-asserted-by":"publisher","DOI":"10.1016\/0021-9681(87)90171-8"},{"key":"2025081710210276000_9.2.e002022.20","doi-asserted-by":"publisher","DOI":"10.1016\/j.jclinepi.2004.03.012"},{"key":"2025081710210276000_9.2.e002022.21","doi-asserted-by":"crossref","first-page":"1499","DOI":"10.1002\/ejhf.2271","article-title":"Heart failure drug titration, discontinuation, mortality and heart failure hospitalization risk: a multinational observational study (US, UK and Sweden)","volume":"23","author":"Savarese","year":"2021","journal-title":"Eur J Heart Fail"},{"key":"2025081710210276000_9.2.e002022.22","doi-asserted-by":"crossref","first-page":"482","DOI":"10.1002\/ehf2.12635","article-title":"Mineralocorticoid receptor antagonist use following heart failure hospitalization","volume":"7","author":"Duran","year":"2020","journal-title":"ESC Heart Fail"},{"key":"2025081710210276000_9.2.e002022.23","doi-asserted-by":"crossref","first-page":"1326","DOI":"10.1002\/ejhf.1182","article-title":"Factors associated with underuse of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction: an analysis of 11 215 patients from the Swedish Heart Failure Registry","volume":"20","author":"Savarese","year":"2018","journal-title":"Eur J Heart Fail"},{"key":"2025081710210276000_9.2.e002022.24","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2012.07.048"},{"key":"2025081710210276000_9.2.e002022.25","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.111.028282"},{"key":"2025081710210276000_9.2.e002022.26","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCHEARTFAILURE.113.000792"},{"key":"2025081710210276000_9.2.e002022.27","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCOUTCOMES.116.002946"},{"key":"2025081710210276000_9.2.e002022.28","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCHEARTFAILURE.113.000709"},{"key":"2025081710210276000_9.2.e002022.29","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehw128"},{"key":"2025081710210276000_9.2.e002022.30","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa040135"},{"key":"2025081710210276000_9.2.e002022.31","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1007\/s00228-019-02782-2","article-title":"Differences in medical treatment and clinical characteristics between men and women with heart failure - a single-centre multivariable analysis","volume":"76","author":"Norberg","year":"2020","journal-title":"Eur J Clin Pharmacol"},{"key":"2025081710210276000_9.2.e002022.32","doi-asserted-by":"crossref","first-page":"1357","DOI":"10.1002\/ejhf.1835","article-title":"Management of low blood pressure in ambulatory heart failure with reduced ejection fraction patients","volume":"22","author":"Cautela","year":"2020","journal-title":"Eur J Heart Fail"},{"key":"2025081710210276000_9.2.e002022.33","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehs337"},{"key":"2025081710210276000_9.2.e002022.34","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(18)32484-X"},{"key":"2025081710210276000_9.2.e002022.35","doi-asserted-by":"crossref","first-page":"923","DOI":"10.1002\/ejhf.1079","article-title":"Potassium and the use of renin-angiotensin-aldosterone system inhibitors in heart failure with reduced ejection fraction: data from BIOSTAT-CHF","volume":"20","author":"Beusekamp","year":"2018","journal-title":"Eur J Heart Fail"},{"key":"2025081710210276000_9.2.e002022.36","doi-asserted-by":"crossref","first-page":"1378","DOI":"10.1002\/ejhf.1793","article-title":"Unravelling the interplay between hyperkalaemia, renin-angiotensin-aldosterone inhibitor use and clinical outcomes. Data from 9222 chronic heart failure patients of the ESC-HFA-EORP heart failure long-term registry","volume":"22","author":"Rossignol","year":"2020","journal-title":"Eur J Heart Fail"},{"key":"2025081710210276000_9.2.e002022.37","doi-asserted-by":"crossref","first-page":"280","DOI":"10.1002\/ehf2.12402","article-title":"Serum potassium and clinical outcomes in heart failure patients: results of risk calculations in 21 334 patients in the UK","volume":"6","author":"Linde","year":"2019","journal-title":"ESC Heart Fail"},{"key":"2025081710210276000_9.2.e002022.38","unstructured":"Holmdahl AJ . Mineralocorticoid receptor antagonists in heart failure: exploring the gap between guideline-directed medical therapy and real-world practice [Doctoral thesis. Ume\u00e5, Sweden: Ume\u00e5 University, 2021."}],"container-title":["Open Heart"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/openhrt-2022-002022","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,17]],"date-time":"2025-08-17T17:21:15Z","timestamp":1755451275000},"score":1,"resource":{"primary":{"URL":"https:\/\/openheart.bmj.com\/lookup\/doi\/10.1136\/openhrt-2022-002022"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,9]]},"references-count":38,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2022,9,1]]},"published-print":{"date-parts":[[2022,9]]}},"alternative-id":["10.1136\/openhrt-2022-002022"],"URL":"https:\/\/doi.org\/10.1136\/openhrt-2022-002022","relation":{},"ISSN":["2053-3624"],"issn-type":[{"value":"2053-3624","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,9]]}}}