Mineralocorticoid receptor antagonists and mortality in hypertension: a systematic review and meta-analysis
Abstract
Background: International guidelines differ in their recommendations for mineralocorticoid receptor antagonist (MRA) use in hypertension, as the effect on mortality is unclear. We meta-analyzed trial-level data to determine the association of MRA use with all-cause mortality in hypertension.
Methods: MEDLINE and EMBASE were searched for randomized clinical trials published from database inception through March 14, 2025, evaluating MRA use in trial populations with at least 85% prevalence of hypertension. The control groups consisted of placebo or usual care. Two reviewers independently screened and extracted data. Pooled estimates were calculated using random-effects and inverse variance models. The primary outcome was all-cause mortality.
Results: Seventeen randomized clinical trials were eligible for inclusion ( n = 25 498), of which 12 trials reported mortality events ( n = 24 426). The mean (±SD) baseline prevalence of hypertension was 95.0% (±5.0), mean baseline SBP was 134.8 (±9.0) mmHg, mean age was 64.1 (±5.3) years and 43.3% ( n = 11 047) were female. The median duration of follow-up was 12 months (interquartile range 9-32 months). MRA use versus control was significantly associated with lower odds of all-cause mortality (12 trials, n = 24 426) (10.7 versus 11.6% over a median follow-up of 20.5 months; odds ratio (OR), 0.91 [95% confidence interval, 95% CI, 0.84-0.99]; absolute risk reduction, 0.88% [95% CI, 0.1-1.7]; I2 = 0.0%).
Conclusion: In this meta-analysis of…
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 25 participants or records.
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