Heart failure & cardiomyopathiesCohort study
Eplerenone vs. spironolactone in heart failure: long-term cardiorenal and mortality outcomes in a registry-based cohort
- observational cohort study
- registry-based new-user cohort
- linked Swedish registries with individual-level laboratory results
- intention-to-treat principle
- multivariable Cox regression
- sensitivity analyses including propensity score matching
Authors' conclusion
Compared with spironolactone, eplerenone was associated with lower all-cause mortality and lower risks of kidney function decline and mild hyperkalaemia. These observational findings warrant confirmation in randomized comparisons.
Study context
- Population
- Adults with a first heart failure (HF) diagnosis in Stockholm County (2005–2019) prescribed either spironolactone or eplerenone within 6 monthsinitiated a mineralocorticoid receptor antagonist, of 75,565 patients with new-onset HF · spironolactone 11,039 · eplerenone 1,007
- Participants
- 12,046 adults
- Exposure
- Eplerenone vs. spironolactone
- eplerenonen = 1,007
- spironolactonen = 11,039reference
Main finding
All-cause mortality
Hazard ratio
0.78
95% CI 0.62–0.98
eplerenone vs spironolactone
hazard ratio 0.78 (95% CI 0.62–0.98)
As reported in the abstract
Observational data: associations, not effects.
Further findings
| Outcome | Estimate | |
|---|---|---|
| More than 50% decline in eGFR · lower with eplerenone | hazard ratio 0.69 (95% CI 0.54–0.88) | |
| Sustained eGFR below 30 mL/min/1.73 m² · lower with eplerenone | hazard ratio 0.69 (95% CI 0.49–0.95) | |
| Composite kidney outcome · lower with eplerenone | hazard ratio 0.71 (95% CI 0.56–0.90) | |
| HF hospitalization — eplerenone vs spironolactone · higher with eplerenone | cause-specific hazard ratio 1.29 (95% CI 1.11–1.51) | |
| HF hospitalization — eplerenone vs spironolactone · attenuated when death was treated as a competing risk | hazard ratio, death as competing risk 0.99 (95% CI 0.87–1.12) | |
| 0.512Ratio (log scale) |
Sensitivity analyses
- Findings were robust across sensitivity analyses
Safety
| Outcome | hazard ratio (95% CI) | |
|---|---|---|
| Hyperkalaemia of 5.5 mmol/L or above · lower with eplerenone | 0.76 (0.60–0.96) | |
| 0.512Hazard ratio (log scale) |
Original publication
Eplerenone vs. spironolactone in heart failure: long-term cardiorenal and mortality outcomes in a registry-based cohort. Eur Heart J Cardiovasc Pharmacother. Published 10 September 2026. doi:10.1093/ehjcvp/pvag064
Summarised from the published abstract; every number is checked against it