Aldosterone receptor antagonism in heart failure.

The renin-angiotensin-aldosterone system plays a major role in the pathophysiology of heart failure. Aldosterone is one of the central mediators involved in the cardiac remodeling process. Its classic effect in heart failure is attributed to mineralocorticoid receptor-mediated salt and fluid retention leading to increased afterload. New evidence demonstrates nonclassic effects of increased collagen synthesis and myocardial fibrosis resulting in left ventricular hypertrophy. Antagonism of aldosterone receptors with spironolactone benefits patients with severe heart failure, and eplerenone benefits those after myocardial infarction who have left ventricular dysfunction. Future research is directed at aldosterone antagonism in patients with mild-to-moderate heart failure, coronary artery disease treated with percutaneous coronary intervention, and nephropathy complicated by diabetes mellitus.