to the editor: I read with interest the article¹ by McConaghy and Smith in American Family Physician, on the outpatient treatment of systolic heart failure. I want to clarify two points. First, the authors correctly note that the Randomized Aldactone Evaluation Study (RALES) showed reductions in mortality and hospitalization in patients with congestive heart failure who received spironolactone (Aldactone). However, publication of these findings was associated with an abrupt increase in the rate of prescriptions for spironolactone and in hyperkalemia-associated morbidity and mortality.² Other studies^3,4 have reported much higher rates of drug discontinuation because of hyperkalemia than those reported in RALES, particularly in the presence of angiotensin-converting enzyme inhibitors. These differences highlight the challenge of translating findings from controlled trials into practice, and suggest the need for intensive monitoring of serum potassium levels in patients receiving spironolactone for this purpose.

Second, the authors correctly note that the first Vasodilator-Heart Failure Trial (V-HeFT I) showed no improvement in overall mortality in patients given a combination of hydralazine (Sorbitrate) plus isosorbide (Apresoline) dinitrate compared with those treated with enalapril (Vasotec). However, a subanalysis⁵ showed benefit for blacks, and the recent African-American Heart Failure Trial (A-HeFT),⁶ involving only blacks, showed a 43 percent reduction in all-cause mortality among patients receiving hydralazine plus isosorbide dinitrate in addition to standard therapy. Both drugs are available generically at modest cost.

editor’s note: This letter was sent to the authors of “Outpatient Treatment of Systolic Heart Failure,” who declined to reply.