Mineralocorticoids and outcome improvement in heart failure patients with and without atrial fibrillation: a systematic review and a meta-analysis

Background: The presence of atrial fibrillation (AF) in patients with heart failure (HF) is common and increases the risk of adverse events. Whether the benefit of mineralocorticoid receptor antagonists (MRAs) in patients with HF varies according to AF remains to be understood. Research design and methods: We systematically searched MEDLINE and EMBASE and included all studies reporting prevalence of AF and incidence of a composite primary outcome of cardiovascular death and HF hospitalization. Random-effects models were used to estimate pooled odds ratios (OR), 95% confidence intervals (CI), and prediction intervals (PI). Results: Two thousand five hundred and eighty-two articles were screened, and five studies were included. Prevalence of AF in HF patients was 34.5% (95% CI: 24.8–45.8%; 95% PI: 9.4–72.8%). MRAs appeared similarly effective in reducing the risk of the primary outcome among HF patients with AF (OR: 0.91; 95% CI: 0.63–1.31) and without AF patients (OR: 0.80; 95% CI: 0.71–0.90) (subgroup difference p = 0.495). Meta-regression identified female sex, hypertension, prior HF hospitalization, and beta-blocker use as potential moderators of the risk of the primary outcome in patients with HF and AF. Conclusions: One-third of HF patients included in RCT trials on MRAs have AF. MRAs improved outcomes with an effect that results not different in HF patients with and without AF. Registration: The PROSPERO identification number is CRD420251007396.