Efficacy of spironolactone in patients with heart failure with preserved ejection fraction following acute myocardial infarction: A multicenter retrospective cohort analysis

BACKGROUND: Heart failure with preserved ejection fraction (HFpEF) following acute myocardial infarction is common, yet evidence-based pharmacotherapy remains limited. This study aims to evaluate the efficacy of spironolactone among patients with HFpEF following acute myocardial infarction. METHODS: We conducted a multicenter retrospective cohort study using data from 82 hospitals across China between January 2010 and March 2024. Patients were stratified into spironolactone users versus non-users. Propensity score matching (PSM) was performed to balance baseline covariates. The primary endpoint was a composite of 1-year heart failure rehospitalization or cardiac death. Time-to-event outcomes were analyzed using Kaplan-Meier curves with log-rank tests. Cox proportional hazards models with cluster-robust variance estimation were used to estimate hazard ratios (HRs). Restricted mean survival time (RMST) analysis was applied to assess survival differences when the proportional hazards assumption was violated. Prespecified subgroup analyses were conducted by age (<65 versus. ≥65 years), sex, hypertension, and diabetes mellitus. RESULTS: Among 4,507 eligible patients, 1,171 matched pairs were included after PSM. Kaplan-Meier analysis showed no significant difference between groups (log-rank P = 0.26). Cox regression yielded an HR of 1.18 (95% CI: 0.89-1.58; P = 0.25). RMST analysis revealed a non-significant difference of - 0.6 days (P = 0.845). All secondary endpoints and subgroup analyses were consistent with the null findings for the primary endpoint. CONCLUSIONS: In this large multicenter retrospective cohort study, spironolactone use was not associated with improved clinical outcomes in patients with HFpEF following acute myocardial infarction.