Expert consensus document on the management of hyperkalaemia in patients with cardiovascular disease treated with renin angiotensin aldosterone system inhibitors: coordinated by the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology

Abstract

Renin angiotensin aldosterone system inhibitors/antagonists/blockers (RAASi) are a cornerstone in treatment of patients with cardiovascular diseases especially in those with heart failure (HF) due to their proven effect on surrogate and hard endpoints. Renin angiotensin aldosterone system inhibitors are also the basis in treatment of arterial hypertension, and they are furthermore indicated to reduce events and target organ damage in patients with diabetes and chronic kidney disease, where they have specific indication because of the evidence of benefit. Renin angiotensin aldosterone system inhibitor therapy, however, is associated with an increased risk of hyperkalaemia. Patients with chronic kidney disease and HF are at increased risk of hyperkalaemia and ∼50% of these patients experience two or more yearly recurrences. A substantial proportion of patients receiving RAASi therapy have their therapy down-titrated or more often discontinued even after a single episode of elevated potassium (K+) level. Since RAASi therapy reduces mortality and morbidity in patients with cardiovascular disease steps should, when hyperkalaemia develops, be considered to lower K+ level and enable patients to continue their RAASi therapy. The use of such measures are especially important in those patients with the most to gain from RAASi therapy.

Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology

“…Hyperkalaemia is an important reason for under‐use of life‐saving therapy with RAASi in HF, and it is particularly frequent in patients with more advanced kidney disease and T2DM . Besides PEARL‐HF (Evaluation of Patiromer in Heart Failure Patients), a phase‐2 trial published in 2011, new evidence is available from trials of patients with CKD and hypertension that also included subgroups of HF patients.…”

“…Hyperkalaemia is an important reason for under-use of life-saving therapy with RAASi in HF, and it is particularly frequent in patients with more advanced kidney disease and T2DM. 32 Besides PEARL-HF (Evaluation of Patiromer in Heart Failure Patients), 33 a phase-2 trial published in 2011, new evidence is available from trials of patients with CKD and hypertension that also included subgroups of HF patients. The subgroup analysis of the AMETHYST-DN (Patiromer in the Treatment of Hyperkalaemia in Patients With Hypertension and Diabetic Nephropathy) trial 34 included 105 HF patients on RAASi.…”

Reappraisal on pharmacological and mechanical treatments of heart failure

“…Chronic kidney disease (CKD) in HF increases the risk of hyperkalaemia [169]. The PEARL-HF trial holds that patiromer (a non absorbed, orally administered, potassium-binding polymer) prevented hyperkalaemia and was relatively well tolerated in patients with HF and a history of hyperkalaemia, resulting in the discontinuation ofrenin-angiotensin-aldosterone system (RAAS) inhibitors and/or beta-adrenergic blocking agents, or in CKD patients with an estimated glomerular filtration rate of < 60 mL/min receiving standard therapy and spironolactone (25-50 mg/day) [170].…”

Cost‐analysis of persistent hyperkalaemia in non‐dialysis chronic kidney disease patients under nephrology care in Italy

“…This holds true even in the ideal setting of tertiary nephrology care, as testified by the high prevalence of sK ≥ 5.0 mEq/L in renal clinics . This picture will change in the near future because of the introduction of two novel binders of potassium, patiromer and sodium zirconium cyclosilicate, that may likely allow to overcome the current HK‐related barrier to optimal RAASI therapy in chronic renal and cardiovascular disease …”

“…5 This picture will change in the near future because of the introduction of two novel binders of potassium, patiromer and sodium zirconium cyclosilicate, that may likely allow to overcome the current HK-related barrier to optimal RAASI therapy in chronic renal and cardiovascular disease. 8,9 When considering this future perspective, attaining a cost analysis of HK is preliminary and functional to the best implementation of the new anti-hyperkaliaemic agents. Few studies have evidenced that HK is a costly event; these studies were however based on retrospective analyses in unselected populations either derived from commercial or insurance databases [10][11][12] or from databases covering primary and secondary care.…”