Mineralocorticoid Receptor Antagonist Use in Contemporary Heart Failure Care

TLDR

This review revisits the role of MRAs across the spectrum of HF, summarises the supporting evidence, discusses their mechanisms of action and provides practical guidance on patient eligibility and initiation strategies, and addresses common barriers that often limit their use.

Abstract

Heart failure (HF) continues to challenge clinicians worldwide, not only because of its high morbidity and mortality but also due to the persistent difficulty in translating therapeutic advances into routine care. Despite the availability of effective treatments, data show striking gaps in the optimal use of guideline-directed medical therapy. Among the four pillars of guideline-directed medical therapy, mineralocorticoid receptor antagonists (MRAs) remain the least prescribed. This underuse is concerning considering the evidence demonstrating consistent benefits of MRAs across different HF phenotypes. In this review, we revisit the role of MRAs across the spectrum of HF. We summarise the supporting evidence, discuss their mechanisms of action and provide practical guidance on patient eligibility and initiation strategies. In addition, we address common barriers that often limit their use. By combining mechanistic insights, trial evidence and pragmatic recommendations, this review aims to facilitate broader and earlier use of MRAs, thereby helping to close a major gap in the implementation of evidence-based HF care.