eplerenone redux

In response to my snark about the recent EMPHASIS-HF study, I wondered if what I said - that patients with EF less than 35% are already on their way to class III/IV heart failure, therefore lessening the impact of this study - was true.

I guess not, according to the American Journal of Cardiology, almost 30 years ago. In their assessment, resting ejection fraction did not correlate whatsoever with symptoms or exercise capacity. But in that case, if symptomatic heart failure is totally dissociated from resting EF, and clinicians are going to institute therapy based on symptoms, why even include an EF cutoff? Because now, physicians considering eplerenone for their mildly symptomatic patients are going to need to do an echo first. Why not have just done a trial of eplerenone for all mildly symptomatic pts with a diagnosis of HF and then look at how patients did depending on their EF?