Association between spironolactone added to beta-blockers and ACE inhibition and survival in heart failure patients with reduced ejection fraction: a propensity score-matched cohort study.

PURPOSE: Heart failure (CHF) guidelines recommend mineralocorticoid receptor antagonists for all symptomatic patients treated with a combination of ACE inhibitors/angiotensin receptor blockers (ARBs) and beta-blockers. As opposed to both eplerenone trials, patients in RALES (spironolactone) received almost no beta-blockers. Since pharmacological properties differ between eplerenone and spironolactone, the prognostic benefit of spironolactone added to this baseline combination therapy needs clarification. METHODS: We included 4,832 CHF patients with chronic systolic dysfunction from the Norwegian Heart Failure Registry and the heart failure outpatients' clinic of the University of Heidelberg. Propensity scores for spironolactone receipt were calculated for each patient and used for matching to patients without spironolactone. RESULTS: During a total follow-up of 17,869 patient-years, 881 patients (27.0 %) died in the non-spironolactone group and 445 (28.4 %) in the spironolactone group. Spironolactone was not associated with improved survival, neither in the complete sample (HR 0.82; 95 % CI 0.64-1.07; HR 1.03; 95 % CI 0.88-1.20; multivariate and propensity score adjusted respectively), nor in the propensity-matched cohort (HR 0.98; 95 % CI 0.82-1.18). CONCLUSION: In CHF outpatients we were unable to observe an association between the use of spironolactone and improved survival when administered in addition to a combination of ACE/ARB and beta-blockers.

[The demographer's point of view]. / Le point de vue du demographe.

PIP: Although the predictable consequence of the acceleration of world population growth were foreseen 40 years ago, the need for population education did not become obvious until much later. Only in the 1960s did a number of countries become aware of changes in population dynamics and their implications for the quality of life and for socioeconomic development goals. Population phenomena and their implications are almost as poorly understood by most persons today as they were when the first population policies were announced. Population education has been viewed as a means of achieving a better understanding of population phenomena. It is believed that acquiring knowledge of population phenomena will promote responsible decision making on questions related to population problems. The early preoccupation in population education with fertility and family planning aroused considerable resistance. There is still strong resistance to including population dynamics and their implications in educational programs. But the most exclusive interest in family planning as a means of reducing the population explosion has broadened in response to a number of events including recognition of family planning as a human right, studies of the effects of high fertility on maternal-child health and education, the mortality decline in developing countries, and the strong increase in migratory movements resulting from urbanization and other causes. The university teaching of demography has become important only recently, and population education at the elementary and secondary level is more recent still. Each educational system must decide for itself the best bode of integrating demographic themes into the different disciplines. The principal demographic themes that should be incorporated will generally fit into existing programs of study. Because of the dynamic nature of demographic phenomena, the content of population education should be reviewed periodically with the assistance of a demographer. New themes appearing in recent years are the AIDS epidemic and the increasingly close interaction between population and the environment. In countries with explicit population policies, adequate information should be available to enable individuals and couples to make informed decisions, and population education is indispensable for this. A problem that is not specifically demographic but that interacts ever more closely with population questions is the elimination of poverty. Attempts to reduce poverty must recognize that the poor are the largest and fastest growing population sector. In coming years, demographers should participate more actively in population education and communication programs, as well as in training of teachers and others involved in these areas. Development of a demographic culture will be required to enable society to deal with the profound changes it must confront in the near future.^ieng