Randomized Placebo-Controlled Trial to Evaluate Effects of Eplerenone on Myocardial Perfusion and Function Among Persons With Human Immunodeficiency Virus (HIV)-Results From the MIRACLE HIV Study

Background. Increased renin angiotensin aldosterone system (RAAS) activity may contribute to excess cardiovascular disease in people with HIV (PWH). We investigated how RAAS blockade may improve myocardial perfusion, injury, and function among well-treated PWH. Methods. Forty PWH, on stable ART, without known heart disease were randomized to eplerenone 50 mg PO BID (n = 20) or identical placebo (n = 20) for 12 months. The primary endpoints were (1) myocardial perfusion assessed by coronary flow reserve (CFR) on cardiac PET or stress myocardial blood flow (sMBF) on cardiac MRI or (2) myocardial inflammation by extracellular mass index (ECMi) on cardiac MRI. Results. Beneficial effects on myocardial perfusion were seen for sMBF by cardiac MRI ( mean [ SD]: 0.09 [0.56] vs - 0.53 [0.68] mL/min/g; P =.03) but not CFR by cardiac PET (0.01 [0.64] vs - 0.07 [0.48]; P =.72, eplerenone vs placebo). Eplerenone improved parameters of myocardial function on cardiac MRI including left ventricular end diastolic volume (-13 [28] vs 10 [26] mL; P =.03) and global circumferential strain (GCS; median [interquartile range 25th-75th]: - 1.3% [-2.9%-1.0%] vs 2.3% [-0.4%-4.1%]; P =.03), eplerenone versus placebo respectively. On cardiac MRI, improvement in sMBF related to improvement in global circumferential strain (rho = -0.65, P =.057) among those treated with eplerenone. Selecting for those with impaired myocardial perfusion (CFR <2.5 and/or sMBF <1.8), there was a treatment effect of eplerenone versus placebo to improve CFR ( 0.28 [ 0.27] vs -0.05 [0.36]; P =.04). Eplerenone prevented a small increase in troponin ( 0.00 [-0.13-0.00] vs 0.00 [0.00-0.74] ng/L; P =.03) without effects on ECMi ( 0.9 [-2.3-4.3] vs -0.7 [- 2.2-0.1] g/m(2); P =.38). CD4+ T-cell count (127 [-38-286] vs -6 [-168-53] cells/ mu L; P =.02) increased in the eplerenone- versus placebo-treated groups. Conclusions. RAAS blockade with eplerenone benefitted key indices and prevented worsening of myocardial perfusion, injury, and function among PWH with subclinical cardiac disease when compared with placebo.