Mineralocorticoid Receptor Antagonists in Type 2 Diabetes

Inclusion Criteria: * Able to understand the written patient information and to give informed consent * Type 2 diabetes mellitus (WHO criteria), diagnosed at least 3 months prior to baseline * Blood pressure treatment according to standard guidelines * Negative pregnancy test (fertile women) * Be willing to change/pause potassium sparing medication * Age 18-85 years * Patients must have high cardiovascular risk factors, defined as one of the following: NT-proBNP ≥ 70 pg/ml (taken within the last 6 months prior to baseline) Albuminuria ( albumin/creatinine ratio ≥ 30 mg/g Confirmed history of myocardial infarction (≥ 3 months prior to baseline) Or patient discharged from hospital with a documented diagnosis of unstable angina within 24 months prior to baseline Evidence of coronary artery disease by CAG in 1 or more major coronary arteries OR at least one of the following: a positive noninvasive stress test, OR a positive stress echocardiography showing regional systolic wall motion abnormalities, OR a positive scintigraphy test showing stress-induced ischemia History of ischemic or hemorrhagic stroke (≥ 3 months prior to informed consent) Presence of peripheral artery disease (symptomatic or not ) documented by either: previous limb angioplasty, stenting or bypass surgery; or previous limb or foot amputation due to circulatory insufficiency; or angiographic evidence of significant (≥ 50%) peripheral artery stenosis in at least one limb; or evidence from a non-invasive measurement of significant (≥50% or as reported as hemodynamically significant) peripheral artery stenosis in at least one limb; or ankle brachial index of ≤ 0.9 Left ventricle hypertrophy: Documented at echocardiography ECG: R-spike in V5/V6 ≥ 25 mm or S-spike in V1 + R-spike in V5/V6 ≥ 35 mm Patients both with and without a cardiovascular risk factor can be randomized to the fat biopsy sub study. Exclusion Criteria: * Allergic to the study medication * Systolic HF (LVEF ≤ 40%) * Impaired kidney function, eGFR ≤ 40 ml/min * Severe liver insufficiency (Child-Pugh class C) * Treatment with MR antagonist within 3 months prior to baseline * Treatment with both ACE inhibitors and Angiotensin II Receptor blockers. * Serum-potassium ≥ 5.0 mmol/l * Serum-sodium ≤ 135 mmol/l * Myocardial infarction, unstable angina pectoris or bypass graft surgery within 3 months prior to baseline * Persistant atrial fibrillation (except for the fat biopsy sub population) * ECG showing malign ventricular arrhythmia or prolonged QT-interval (\> 500ms) * Untreated heart valve disease * ICD-unit/pacemaker * Pregnancy or desire hereof or breastfeeding * Women in the fertile age not using safe contraceptives (spiral, hormonal contraceptives) * Cancer unless complete remission ≥ 5 year * Alcohol-/drug-abuse * Inflammatory bowel disease * Other concomitant disease or treatment that according to the investigator's assessment makes the patient unsuitable to participate in the study * Simultaneous participation in another clinical study * Treatment with CYP3A4-inhibitors (e.g. itraconazol, etoconazol, ritonavir, nelfinavir, clarithromycin, telithromycin and nefazodon)