Carlos Calvo-Garrido

Neus Teixidó

Josep Usall

Rosario Torres

Nicolas Aveline

Marc Fermaud

Botrytis

Botrytis bunch rot in vineyards: still a challenge for commercial biological control products and novel microbial antagonists

Biological and integrated control of plant pathogens IOBC-WPRS Bulletin Vol. 133, 2018 pp. 18-19 Botrytis bunch rot in vineyards: still a challenge for commercial biological control products and novel microbial antagonists 3 Institut Français de la Vigne et du Vin, 33290 Blanquefort, France e-mail: carlos.calvo-garrido@bordeaux.inra.fr Abstract: The grey mould or botrytis bunch rot (BBR), caused by Botrytis cinerea, is the most important fungal disease in ripening grapevine bunches late in the growing season. The effects involve losses in yield as well as remarkable faults in wine quality. Biological control using antagonistic microorganisms is considered as a suitable alternative to control BBR in the field. After more than 20 years of research in biological control of BBR, grapevine growers have a little choices, i.e., in Europe only three products, based on biological control agents (BCAs), are commercially available. However, some other microorganisms are following the registration procedure and should be available in the near future. In addition, several research units in Europe are also investigating new biological control agents. The case study of Candida sake CPA-1 represents a long development process from laboratory to field application, including improved formulations, beforehand physiological adaptation of the strain, and high control levels in the field. Another interesting case study is the selection process of bacterial BCAs based on efficacy, mode of action, survival and persistence on berry surface, followed by a further field screening step involving four candidate strains, in which Bacillus ginsengihumi S38 resulted to be effective. Both are good examples of the methodologies and strategies needed to achieve effective biological control in the field, while they bring up the discussion on the appropriateness of selection process steps to follow. When applied in vineyards, commercial BCA products present efficacy rates that are sometimes variable and may depend on climatic conditions. Therefore, three different research programs at INRA Bordeaux-Aquitaine have focused in field efficacy of biological control products, in partnership with the French Institute of Grapevine & Wine (IFV), and the Gironde Agriculture Chamber. From 2012 to 2017, we tested commercial products based on Aureobasidium pullulans, Bacillus subtilis and Bacillus amyloliquefaciens, as well as other BCAs in a developmental stage. The goals were: 1) to compare efficacy levels in commercial vineyards of registered products (or close to registration) in order to give advice to local growers in South-West of France, and 2) to test new microbial antagonists in experimental vineyards to improve its efficacy and confirm its potential as future BCAs against BBR. The results of these experiments have showed the comparative success of some of the BCAs compared to others. The commercial products have shown partial efficacy, not always significant, and highly variable according to the site*season conditions. As for the novel BCAs of prime importance, the efficacy results of both C. sake CPA-1 and B. ginsengihumi S38 showed similar control rates than registered, or close to registration, BCA products. The amount of field tests along 5 years of experiments, allows us to extract some conclusions about the reliability of BCA products in SO France region, as well as to confirm the potential of other microbial antagonists. This experience motivates the discussion on how to improve BCA performance in vineyards, based in some axes, such as: application timing regarding mode of action, application following Disease Support System, survival and persistence on vine organs, formulation, and combinational strategies. Key words: Vitis vinifera, natural products, biocontrol, wine grapes, disease risk model

  Carlos Calvo-Garrido1 , Neus Teixidó2 , Josep Usall2 , Rosario Torres2 , Nicolas Aveline3 , Marc Fermaud1 1 SAVE, INRA, Bordeaux Science Agro, ISVV, 33882 Villenave d'Ornon, France; 2 IRTA, XaRTA-Postharvest, Edifici Fruitcentre, Parc Científic i Tecnològic Agroalimentari de Lleida, Parc de Gardeny, 25003 Lleida, Catalonia, Spain;


Dr João Pedro Ferreira
email: j.ferreira@chru-nancy.fr

Timothy Collier

Andrew L Clark

Mamas A Mamas

Hans-Peter Brunner-

La Rocca

Stephane Heymans

Arantxa González

Fozia Z Ahmed

Johannes Petutschnigg

Blerim Mujaj

Joe Cuthbert

Philippe Rouet

Pierpaolo Pellicori

Beatrice Mariottoni

Franco Cosmi

Frank Edelmann

Lutgarde Thijs

Jan A Staessen

Mark Hazebroek

Job Verdonschot

Patrick Rossignol

Nicolas Girerd

John G Cleland

Faiez Zannad

Spironolactone effect on the blood pressure of patients at risk of developing heart failure: an analysis from the HOMAGE trial

Keywords: cardiovascular risk, hypertension, spironolactone, renin

Abstract

Background: Uncontrolled blood pressure (BP) increases the risk of developing heart failure (HF). The effect of spironolactone on BP of patients at risk of developing HF is yet to be determined.

Aims: To evaluate the effect of spironolactone on the BP of patients at risk for HF and whether renin can predict spironolactone`s effect.

Methods: HOMAGE (Heart OMics in Aging) was a prospective multicenter randomized openlabel blinded end-point (PROBE) trial including 527 patients at risk for developing HF randomly assigned to either spironolactone (25-50mg/day) or usual care alone for a maximum of 9 months. Sitting BP was assessed at baseline, month 1 and 9 (or last visit).

Analysis of covariance (ANCOVA), mixed effects models, and structural modelling equations were used.

Results:

The median (percentile 25-75 ) age was 73 (69-79) years, 26% were female, and >75% had history of hypertension. Overall, the baseline BP was 142/78mmHg. Patients with higher BP were older, more likely to have diabetes and less likely to have coronary artery disease, had greater left ventricular mass (LVM), and left atrial volume (LAV). Compared with usual care, by last visit, spironolactone changed SBP by -10.3 (-13.0 to -7.5)mmHg and DBP by -3.2 (-4.8 to -1.7)mmHg (p<0.001 for both). A higher proportion of patients on spironolactone had controlled BP <130/80mmHg (36 vs. 26%; p=0.014). Lower baseline renin levels predicted a greater response to spironolactone (interaction p =0.041).

Conclusion:

Spironolactone had a clinically important BP-lowering effect. Spironolactone should be considered for lowering blood pressure in patients who are at risk of developing HF.

Introduction

Hypertension is the most prevalent cardiovascular condition worldwide and is a risk factor for developing heart failure (HF) [START_REF] Kearney | Global burden of hypertension: analysis of worldwide data[END_REF][START_REF] Vasan | Impact of high-normal blood pressure on the risk of cardiovascular disease[END_REF] . Prevention of new onset HF can be achieved with an optimal blood pressure (BP) control in patients with hypertension [START_REF] Thomopoulos | Effects of blood pressure-lowering treatment. 6. Prevention of heart failure and new-onset heart failure--meta-analyses of randomized trials[END_REF] . After the publication of SPRINT (Randomized Trial of Intensive versus Standard Blood-Pressure Control), showing a benefit of an intensive BP lowering strategy vs. a less intensive one in patients with high CV risk [START_REF] Wright | A Randomized Trial of Intensive versus Standard Blood-Pressure Control[END_REF] ; hypertension guidelines lowered the BP target to lower than 130/80 mmHg [START_REF] Whelton | ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines[END_REF][START_REF] Williams | ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension[END_REF] .

In PATHWAY-2, spironolactone (compared to bisoprolol, doxazosin and placebo) was the most effective add-on BP-lowering treatment in patients with resistant hypertension [START_REF] Williams | Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial[END_REF] .

However, the role of spironolactone for lowering and controlling BP in patients with a high risk of progressing towards HF, is not well established. HOMAGE (Heart OMics in Aging) was a prospective multicenter randomized open blinded end-point (PROBE) trial including people at risk for developing HF for assessing the effect of spironolactone on fibrosis and cardiac remodelling [START_REF] Cleland | The effect of spironolactone on cardiovascular function and markers of fibrosis in people at increased risk of developing heart failure: the heart 'OMics' in AGEing (HOMAGE) randomized clinical trial[END_REF] . In HOMAGE, the effect of spironolactone in the BP of people with and without hypertension at baseline has not been reported yet [START_REF] Pellicori | Effects of spironolactone on serum markers of fibrosis in people at high risk of developing heart failure: rationale, design and baseline characteristics of a proof-of-concept, randomised, precision-medicine, prevention trial. The Heart OMics in AGing (HOMAGE) trial[END_REF] . Furthermore, there is a strong rationale supporting the hypothesis that spironolactone might have a more pronounced BPlowering effect among people with lower renin levels, which can be a good surrogate of sodium retention [START_REF] Williams | Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial[END_REF] .

In this prespecified secondary analysis, we investigated the effect of spironolactone on BP and its interaction with baseline renin levels, and whether BP could mediate the antifibrotic and anti-remodelling effects of spironolactone.

Methods

Trial design and population

The HOMAGE trial had a prospective, randomised, open-label, blinded-endpoint (PROBE), multicentre design, in which people at increased risk of developing HF were randomly assigned to receive either spironolactone or "control" -not receiving spironolactone or another mineralocorticoid receptor antagonist (MRA) (ClinicalTrials.gov Identifier: NCT02556450). The rationale, trial design and main results have been published [START_REF] Pellicori | Effects of spironolactone on serum markers of fibrosis in people at high risk of developing heart failure: rationale, design and baseline characteristics of a proof-of-concept, randomised, precision-medicine, prevention trial. The Heart OMics in AGing (HOMAGE) trial[END_REF] . The study was approved by all relevant ethics committees and regulatory bodies. All participants provided written informed consent prior to study-specific procedures. The main participating criteria included age of 65 or older (amended to 60 years during the course of the trial), cardiovascular risk defined by the presence of coronary artery disease or at least 2 of the following: diabetes, treated hypertension, microalbuminuria, abnormal ECG, and a NT-pro BNP between 125 and 1,000 ng/L (14.

Endpoints, patients and follow-up

Participants were randomized to either spironolactone (25-50 mg/day; n =265) or control (n =262). The median (percentile 25-75 ) follow-up time was 8.9 (6.0-9.2) months. The primary endpoint was the interaction between the treatment and the baseline levels of galectin-3 for the change in serum concentrations of PIIINP from baseline to the end of follow-up ("9month visit"). Secondary aims were to investigate the effects of spironolactone on the change (from baseline to the end of follow-up) of other markers of collagen metabolism PICP and collagen type I-C terminal telopeptide (CITP), NT-pro BNP, echocardiographic measures of cardiac structure and function, and signs/symptoms. One-month changes were also assessed in exploratory analyses [START_REF] Cleland | The effect of spironolactone on cardiovascular function and markers of fibrosis in people at increased risk of developing heart failure: the heart 'OMics' in AGEing (HOMAGE) randomized clinical trial[END_REF] .

Blood pressure assessment

As specified in the protocol, at each main study visit (baseline, month 1, and month 9 [or last visit]), office BP was measured 3 times (with a 1-minute interval between measurements) with the participant in the sitting position after he/she had rested for at least 10 minutes. An electronic sphygmomanometer was used in the non-dominant arm and the mean of the 3 measurements was calculated. The devices and cuff sizes were used at the discretion of each participating centre. The BP measurements were performed in a quiet room where a study investigator could be present.

Renin measurement

Baseline plasma renin was determined using a proximity extension assay (PEA) technology (Olink Proseek® Multiplex), that provides Log2 normalized protein expression (NPX) data wherein a high protein value corresponds to a high protein concentration, but not an absolute quantification. A detailed description of the Olink® technology can be found on the website: https://www.olink.com/.

Statistical considerations

The characteristics of patients at baseline were compared between categories of SBP (<120, 120-139, 140-159, and ≥160 mmHg) and SBP ≥130 or DBP ≥80 mmHg (vs. <130/80 mmHg), using comparison of proportions, means or medians as appropriate. The BP change from baseline to month 1 and last visit was studied using analysis of covariance (ANCOVA), where a linear regression model was fitted, with the BP change as outcome variable, the binary variable to indicate the treatment group (control/spironolactone) as explanatory variable, and age, sex, eGFR plus the baseline BP value as adjustment variables. Residual analysis was used to examine the fit of the model. No data transformation was required to meet the assumptions of linear regression. Treatment-by-covariate interaction terms were fitted in regression models using the BP changes from baseline to the last visit as outcome variable.

The baseline covariates tested as interaction terms were age, sex, eGFR, galectin-3, body mass index (BMI), waist circumference (WC), use of angiotensin converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), thiazides, and plasma renin levels.

These variables were chosen due to their clinical importance (age, sex, renal function, obesity and use of background anti-HT therapy), galectin-3 was the prespecified interaction term in the HOMAGE trial [START_REF] Cleland | The effect of spironolactone on cardiovascular function and markers of fibrosis in people at increased risk of developing heart failure: the heart 'OMics' in AGEing (HOMAGE) randomized clinical trial[END_REF] , and renin was found to predict the response to spironolactone in the PATHWAY-2 trial [START_REF] Williams | Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial[END_REF] . The effect of spironolactone on BP was also assessed in baseline BP subgroups, ≥130/80 and <130/80 mmHg. Multilevel mixed effect models were used to assess the BP changes over time, using age, sex, eGFR and the baseline BP as fixed effects, plus an interaction between treatment and visit time (in months), and random effects fitted at the patient level. To assess whether the spironolactone effect on variables of interest previously found to be modified by the treatment (NT-pro BNP, PICP, body surface area indexed left ventricular mass [LVMi] and left atrial volume [LAVi] 8 ) was mediated by the change in SBP, structure equations modelling were used with the aforementioned variables of interest as dependent variables, the treatment (spironolactone or control) as the independent variable, and SBP change as the mediator variable. The direct, indirect and total effects were estimated. No data imputation was performed. No correction for multiplicity of tests was applied due to the exploratory nature of the study. The hypothesis that renin levels might interact with the effect of spironolactone on BP was prespecified because of the results of PATHWAY-2. All analyses were performed using Stata® (version 16,

StataCorp LP).

Results

Baseline characteristics by blood pressure values

The median (percentile 25-75 ) age was 73 (69-79) years, 26% were female, and >75% had a history of hypertension. The mean baseline BP was 142/78 mmHg and 70% of the participants had a BP ≥130 or 80 mmHg. Patients with higher SBP were older, had a lower prevalence of coronary artery disease, and a greater prevalence of diabetes. They were more likely to use thiazide-type diuretics, and had greater LVMi and LAVi. The biomarker levels were not significantly different between groups. Table 1. The characteristics of the patients with a SBP ≥130 or a DBP ≥90 mmHg vs. those with a SBP <130 or DBP <80 mmHg is presented in the Supplemental Table 1. The proportion of patients with presumed "resistant hypertension" defined as a BP ≥130/80 mmHg plus the use of 3 or more antihypertensive drugs including a diuretic was low (2.8%; n =15).

Spironolactone effect on blood pressure

Spironolactone treatment changed SBP by -6.3 (-8.9 to -3.8) mmHg at month 1 and -10.1 (-12.8 to -7.4) at the last visit; the corresponding changes for DBP were -2.5 (-4.1 to -1.0) and -3.2 (-4.8 to -1.7) mmHg. Table 2. Patients whose baseline BP was ≥130/80 mmHg had a greater BP reduction with spironolactone treatment at last visit. Table 3. In the control group, patients with higher BP regressed towards a lower BP throughout follow-up, whereas patients with lower BP regressed towards a higher BP. Beyond lowering BP, spironolactone also avoided the BP increase in patients with lower baseline BP and more patients achieved an adequate BP control on the spironolactone group. Figures 1 &2. The BP-lowering effect of spironolactone was not modified by age, sex, eGFR, diabetes, galectin-3, BMI, WC, ACEi, ARB or thiazide-diuretic use. Figure 3. However, the effect was modified by plasma renin levels, where patients with lower renin had a greater BP reduction with spironolactone than patients with higher renin (p for interaction =0.041). Figure 4. Patients with higher renin (above the median) were older, more likely to be male, and to have diabetes and hypertension, they were more often treated with thiazides, had higher BMI, lower eGFR, hemoglobin, and PICP, and higher galectin-3 levels. Patients with lower renin levels had higher systolic and diastolic BP. Baseline renin levels were not significantly different between treatment groups. Supplemental Table 2.

Mediation analysis

The effect of spironolactone on LAVi could be partly (≈19%) mediated by the change in SBP (p =0.048). The effect on NT-pro BNP, PICP, and LVMi were less influenced by the SBP change. Supplemental Table 3. It should also be noted that the direct effect of spironolactone on LVMi was of small magnitude and did not reach statistical significance.

The correlations between the change in SBP and LAVi, NT-pro BNP, PICP, and LVMi were weak (Spearman Rho <0.2 for all) and are presented in the Supplemental Table 4.

Discussion

Several clinically relevant observations are reported in this study. The BP-lowering effect of spironolactone in a population with high CV risk (and without resistant hypertension) was clinically important, with SBP reductions (vs. control) greater than 10 mmHg at 9 months. Lower plasma renin levels could identify patients in whom spironolactone was more effective in lowering BP; findings that are similar to those of the PATHWAY-2 study, where the BP-lowering effects of spironolactone were more marked among people with lower baseline renin [START_REF] Williams | Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial[END_REF] . Together, these findings support the "salt retention hypothesis" and suggest that, despite the neurohormonal activation, plasma renin can be suppressed by sodium retention, and spironolactone may be more effective in patients with greater sodium retention and/or higher expression of the mineralocorticoid receptor, as supported by prior studies [START_REF] Rabinowe | Renin suppression by saline is blunted in nonmodulating essential hypertension[END_REF] . Moreover, in HOMAGE patients with lower baseline renin had higher systolic and diastolic BP, similar to the findings of other cohorts [START_REF] Joseph | The Association of Serum Aldosterone and Plasma Renin Activity with Ambulatory Blood Pressure in African Americans: The Jackson Heart Study[END_REF][START_REF] Hundemer | Renin Phenotypes Characterize Vascular Disease, Autonomous Aldosteronism, and Mineralocorticoid Receptor Activity[END_REF][START_REF] Brown | The Spectrum of Subclinical Primary Aldosteronism and Incident Hypertension[END_REF][START_REF] Satoh | Aldosterone-to-renin ratio and home blood pressure in subjects with higher and lower sodium intake: the Ohasama study[END_REF][START_REF] Weinberger | Definitions and characteristics of sodium sensitivity and blood pressure resistance[END_REF] . Therefore, spironolactone targeting the low renin physiology, can improve BP control [START_REF] Joseph | The Association of Serum Aldosterone and Plasma Renin Activity with Ambulatory Blood Pressure in African Americans: The Jackson Heart Study[END_REF] .

Patients enrolled in HOMAGE have characteristics comparable to those with HF with preserved ejection fraction (HFpEF) than to patients with resistant hypertension (patients with "presumed" resistant hypertension represented less than 3% of the HOMAGE population) [START_REF] Pellicori | Effects of spironolactone on serum markers of fibrosis in people at high risk of developing heart failure: rationale, design and baseline characteristics of a proof-of-concept, randomised, precision-medicine, prevention trial. The Heart OMics in AGing (HOMAGE) trial[END_REF] . In patients with HFpEF enrolled in the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial, spironolactone reduced SBP by -3.7 ± 0.9 (SE) mmHg [START_REF] Pitt | Spironolactone for heart failure with preserved ejection fraction[END_REF][START_REF] Pfeffer | Regional Variation in Patients and Outcomes in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) Trial[END_REF] . The difference was greater in TOPCAT patients with presumed resistant hypertension in whom spironolactone decreased SBP by -6.1 (-8.9 to -3.3) mmHg and DBP by -2.9 (-4.6 to -1.2) mmHg during the first 8 months of follow-up [START_REF] Rossignol | Spironolactone and Resistant Hypertension in Heart Failure With Preserved Ejection Fraction[END_REF] . In contrast, among patients with heart failure and reduced ejection fraction (HFrEF) included in the RALES (Randomized Aldactone Evaluation Study) and EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure) studies, the MRAs (spironolactone and eplerenone) had only a minor BP reduction effect (-1 to 2 mmHg from baseline to 6 months) [START_REF] Serenelli | Mineralocorticoid Receptor Antagonists, Blood Pressure, and Outcomes in Heart Failure With Reduced Ejection Fraction[END_REF] . Patients with preserved left ventricular ejection fraction (regardless of HF signs or symptoms) have smaller left ventricular end-diastolic volumes and a steeper slope of the end-diastolic to end-systolic pressure-volume ratio than patients with reduced ejection fraction [START_REF] Van De Bovenkamp | Angiotensin-Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction[END_REF] . As a consequence, a similar decrease in systemic vascular resistance in patients with preserved ejection fraction results in a smaller increase in stroke volume but a larger reduction in systemic BP than in patients with reduced ejection fraction who may experience higher stroke volume rise and lower BP drop [START_REF] Schwartzenberg | Effects of vasodilation in heart failure with preserved or reduced ejection fraction implications of distinct pathophysiologies on response to therapy[END_REF] .

The mediation analysis suggests that the effect of spironolactone on PICP change was not mediated by the BP drop, which may indicate a direct anti-fibrotic effect of spironolactone; an hypothesis that has also been supported by animal models [START_REF] Brilla | Antifibrotic effects of spironolactone in preventing myocardial fibrosis in systemic arterial hypertension[END_REF] . Furthermore, when assessing the effect of spironolactone in multiple circulating protein markers, the effect on the markers of collagen synthesis is the strongest [START_REF] Ferreira | Proteomic and Mechanistic Analysis of Spironolactone in Patients at Risk for HF[END_REF] , independently of BP [START_REF] Ferreira | Potential spironolactone effects on collagen metabolism biomarkers in patients with uncontrolled blood pressure[END_REF] . The spironolactone effect on LAVi could have been partly mediated by the reduction in BP. The LAV may change in consequence of hemodynamic alterations, which supports our findings [START_REF] Christensen | Association Between Left Atrial Dilatation and Invasive Hemodynamics at Rest and During Exercise in Asymptomatic Aortic Stenosis[END_REF] .

These findings can be applied to spironolactone doses commonly used in clinical practice (25-50 mg/day), as the dose of spironolactone used in the HOMAGE trial was similar to the dose used in PATHWAY-2 (25-50 mg/day) and in HF trials (25 mg/day uptitrated to 50, if tolerated.

Limitations

Blood pressure was measured in the clinics during the trial visits, which could have increased the BP values compared to home-or 24h ambulatory BP values [START_REF] Banegas | Clinic Versus Daytime Ambulatory Blood Pressure Difference in Hypertensive Patients: The Impact of Age and Clinic Blood Pressure[END_REF] . However, due to consistency of the effects in subgroups and the replication of similar results in other settings and populations, these findings may be regarded as robust.

Conclusion

Spironolactone had a clinically important BP-lowering effect and should be considered for lowering blood pressure in patients who are at risk of developing HF. *The BP lowering effect of spironolactone was greater in patients with higher baseline SBP (≥130/80 mmHg), p for interaction =0.015. 3.

Funding

Baseline renin levels were similar between spironolactone and control groups: mean±SD =7.0±0.9 NPX in both groups, p =0.61. Baseline renin levels were similar between spironolactone and control groups: mean±SD =7.0±0.9 NPX in both groups, p =0.61.

See the methods section for more details.

  8 and 118.2 pmol/L) or BNP between 35 and 280 ng/L (4.1 and 33.1 pmol/L). The main exclusion criteria were glomerular filtration rate (eGFR) <30 mL/minute/1.73m2, serum potassium >5.0 mmol/L, left ventricular ejection fraction <45%, a diagnosis of HF or treatment with loop diuretics, and atrial fibrillation/flutter.

Figure 1 .

 1 Figure 1. Treatment effect on blood pressure by baseline values

Figure 2 .

 2 Figure 2. Proportion of patients with controlled blood pressure over time

Figure 3 .

 3 Figure 3. Blood pressure lowering across age and renal function stratified by sex

Figure 4 .

 4 Figure 4. Treatment effect across the baseline circulating renin levels

Table 1 .

 1 Patients` characteristics by groups of baseline systolic blood pressure (in mmHg)

	Characteristic	<120	120-139	140-159	≥160	p-value
	N.	64	185	179	90
	Age, yr	71.5 ± 7.2	72.8 ± 6.3	74.0 ± 6.7	75.4 ± 5.9	0.001
	Female	14 (21.9%)	40 (21.6%)	48 (26.8%)	30 (33.3%)	0.17
	Smoker	7 (10.9%)	20 (10.8%)	12 (6.7%)	5 (5.6%)	0.36
	CAD	54 (84.4%)	137 (74.1%)	125 (69.8%)	55 (61.1%)	0.013
	MI	38 (70.4%)	85 (61.6%)	65 (52.0%)	23 (41.8%)	0.009
	PCI	45 (83.3%)	96 (69.6%)	80 (64.0%)	37 (67.3%)	0.080
	CABG	14 (25.9%)	40 (29.0%)	60 (48.0%)	22 (40.0%)	0.004
	Diabetes	15 (23.4%)	82 (44.3%)	78 (43.6%)	40 (44.4%)	0.020
	Hypertension	31 (48.4%)	147 (79.5%)	147 (82.1%)	82 (91.1%)	<0.001
	Stroke/TIA	1 (1.6%)	10 (5.4%)	8 (4.5%)	9 (10.0%)	0.12
	COPD	5 (7.8%)	10 (5.4%)	15 (8.4%)	2 (2.2%)	0.22
	Antiplatelet agent	53 (82.8%)	149 (80.5%)	137 (76.5%)	67 (74.4%)	0.49
	Beta-blocker	52 (81.3%)	127 (68.6%)	124 (69.3%)	56 (62.2%)	0.092
	ACEi	30 (46.9%)	108 (58.4%)	89 (49.7%)	45 (50.0%)	0.25
	ARB	17 (26.6%)	47 (25.4%)	45 (25.1%)	34 (37.8%)	0.13
	CCB	6 (9.4%)	40 (21.6%)	43 (24.0%)	19 (21.1%)	0.099
	Thiazide	5 (7.8%)	26 (14.1%)	31 (17.3%)	24 (26.7%)	0.011
	Statin	54 (84.4%)	155 (83.8%)	150 (83.8%)	67 (74.4%)	0.21
	BMI, Kg/m 2	28.0 ± 4.7	29.0 ± 5.3	28.8 ± 5.0	29.3 ± 4.9	0.48
	SBP, mmHg	111.8 ± 5.8	130.5 ± 6.0	149.0 ± 6.1	174.0 ± 11.5	<0.001
	DBP, mmHg	70.2 ± 8.8	76.6 ± 9.6	80.2 ± 10.0	84.5 ± 10.8	<0.001
	Heart rate, bpm	60.1 ± 8.8	61.7 ± 9.6	62.7 ± 9.4	61.7 ± 10.1	0.32
	LVEF, %	61.3 ± 6.3	61.9 ± 7.2	61.5 ± 6.3	64.0 ± 6.5	0.065
	LVMi, g/m 2	92.5 ± 28.7	96.4 ± 24.9	99.2 ± 25.8	105.6 ± 27.9	0.018
	LAVi, ml/m 2	29.6 ± 9.2	30.5 ± 7.8	32.9 ± 9.9	32.2 ± 9.0	0.045
	E/E` ratio	9.3 ± 3.5	9.5 ± 3.3	10.1 ± 3.1	10.8 ± 3.5	0.016
	E/A ratio	0.9 ± 0.3	0.9 ± 0.3	0.9 ± 0.3	0.9 ± 0.3	0.34
	TAPSE, mm	20.9 ± 6.0	22.4 ± 6.7	21.4 ± 6.4	23.0 ± 6.4	0.16
	MAPSE, mm	14.8 ± 3.2	15.6 ± 3.1	15.5 ± 3.3	15.6 ± 2.8	0.38
	eGFR, ml/min	72.3 ± 18.5	74.3 ± 19.7	74.0 ± 18.6	71.7 ± 18.6	0.68
	eGFR <60	17 (26.6%)	39 (21.1%)	37 (20.7%)	23 (25.6%)	0.65
	Hemoglobin, g/dl	13.9 ± 1.6	14.1 ± 1.3	13.9 ± 1.4	14.0 ± 1.4	0.76
	Sodium, mmol/l	138.9 ± 3.1	139.3 ± 2.9	139.5 ± 2.7	139.4 ± 2.7	0.63
	Potassium, mmol/l	4.3 ± 0.4	4.3 ± 0.3	4.3 ± 0.4	4.3 ± 0.4	0.67
	Urea, mmol/l	6.5 (5.5, 14.5)	9.0 (6.0, 15.0)	8.6 (5.6, 14.3)	9.5 (5.8, 13.6)	0.36
	NT-pro BNP, ng/l	221 (137, 430)	191 (121, 299)	215 (143, 342)	247 (159, 369)	0.063
	Galectin-3, ng/ml	17.9 ± 5.6	16.8 ± 5.0	17.0 ± 4.9	17.9 ± 6.1	0.24
	PICP, ng/ml	84.1 ± 25.7	84.6 ± 26.4	83.8 ± 29.2	86.6 ± 26.1	0.88
	PIIINP, ng/ml	7.7 ± 2.5	7.7 ± 2.5	7.7 ± 2.7	7.8 ± 2.7	0.99
	CITP, ug/l	4.2 ± 2.1	4.2 ± 2.1	4.3 ± 2.5	4.2 ± 2.0	0.92
	PICP/CITP ratio	23.8 ± 12.6	23.6 ± 12.1	22.4 ± 9.5	23.3 ± 9.4	0.71
	Renin (NPX)	7.2 ± 0.7	7.1 ± 0.9	7.0 ± 0.9	6.8 ± 1.0	0.15

Table 2 .

 2 Blood pressure effect of spironolactone in the trial population No significant interaction was found between the spironolactone effect on the change of SBP or DBP and (baseline) age, sex, estimated glomerular filtration rate, galectin-3 levels body mass index, waist circumference, angiotensin converting enzyme inhibitor, angiotensin receptor blocker, thiazides, and diabetes.

		SBP change
		Control	Spironolactone Difference (95%CI)*	P-value
	Month 1 (n=498)	-3.4 (16.1)	-9.5 (16.7)	-6.3 (-8.9 to -3.8)	<0.001
	Month 9 (n=481)	-3.3 (19.5)	-13.2 (17.5)	-10.1 (-12.8 to -7.4)	<0.001
		DBP change
		Control	Spironolactone Difference (95%CI)*	P-value
	Month 1 (n=498)	-0.1 (11.1)	-2.5 (8.4)	-2.5 (-4.1 to -1.0)	0.003
	Month 9 (n=481)	-1.3 (10.0)	-4.4 (9.1)	-3.2 (-4.8 to -1.7)	<0.001
	Legend: SBP, systolic blood pressure; DBP, diastolic blood pressure.

*

Table 3 .

 3 Blood pressure effect of spironolactone by baseline blood pressure subgroups BP, blood pressure; SBP, systolic blood pressure; DBP, diastolic blood pressure.

	BP≥130/80 mmHg
		SBP change
	n=373	Control	Spironolactone Difference (95%CI)* P-value
	From bsl to last visit	-5.3 (20.4)	-16.9 (17.1)	-11.9 (-15.2 to -8.7) <0.001
		DBP change
	n=372	Control	Spironolactone Difference (95%CI)* P-value
	From bsl to last visit	-2.1 (10.4)	-6.0 (9.0)	-3.8 (-5.6 to -2.0)	<0.001
	BP<130/80 mmHg
		SBP change
	n=108	Control	Spironolactone Difference (95%CI)* P-value
	From bsl to last visit	3.6 (14.1)	0.1 (11.7)	-4.7 (-9.3 to -0.1)	0.045
		DBP change
	n=108	Control	Spironolactone Difference (95%CI)* P-value
	From bsl to last visit	1.5 (8.0)	1.1 (7.3)	-0.7 (-3.5 to 2.1)	0.61
	Legend:

Disclosures

The authors report having no conflicts of interest with regards to the content of this manuscript.