LAUSR

This article refers to ‘Temporal trends in initiation of mineralocorticoid receptor antagonists and risk of subsequent withdrawal in patients with heart failure: a nationwide study in Denmark from 2003–20 1 7’ by D. Zahir et al. , published in this issue on pages 539–547. The steroidal mineralocorticoid receptor antagonists (MRAs) reduce mortality and hospitalizations for heart failure (HHF) in patients with heart failure and a reduced ejection fraction (HFrEF). Their incorporation into US and European guidelines as a class I indication for HFrEF held the promise for a substantial reduction in cardiovascular mortality, HHFs, and consequentially health care costs. It is therefore discouraging to observe that despite a class I indication in guidelines, over several years their use remains suboptimal in comparison to the other major guideline-recommended therapies for HFrEF. In this issue of the Journal, Zahir et al. 1 report upon the temporal trends in initiation and subsequent withdrawal of an MRA from a nationwide study of 5 1 5 1 2 patients with HFrEF in Denmark from 2003 to 20 1 7. They found that only 40% of patients initiated an MRA within 6 months of their heart failure (HF) diagnosis. Further-more, the use of an MRA did not increase significantly over the past decade. In those in whom an MRA was initiated, 49% of patients discontinued them and only 40% of these patients restarted them. The suboptimal use of MRAs in patients with HFrEF in Denmark 1 is unfortunately not unique. The US Get With the Guidelines Heart Failure Registry (GWTG-HF) 2 also found that the use of MRAs