The Management of Co-Morbidities in Patients with Heart Failure – Potassium Balance

Abstract

Both hypokalaemia and hyperkalaemia are common in HF patients. They are each associated both with HF and with the many drugs used for HF. They are important as they both can aggravate ventricular arrhythmias, both can cause symptoms in HF patients and in the case of hyperkalaemia in particular, are a common reason not to prescribe or reduce the dose of or even cease use of effective medication with life- prolonging benefits in HFrEF, including ACEI’s and MRA’s. Treatment optiosn for bioth hypokalaemia and hyperkalaemia are discussed including the emerging evidence that agents such as patiromer may be safe and effective agents to be used long-term in high-risk patients with HF to allow them to take doses of RAAS inhibitors in particular which they otherwise may not be able to take. This might allow them to continue to receive the mortality morbidity benefits these treatments confer.

Ageing, demographics, and heart failure

“…This is despite, along with the elderly, in general, women and patients with comorbidities being selectively not recruited into major clinical trials in HF. There are some particular features in the older patient with HF, which potentially make them less tolerant to drug therapy and more prone to medication errors and side effects 41 . These include dementia and cognitive decline, anorexia, 42 muscle wasting, 43–45 and frailty 46–48 all of which more common in the elderly 49 , 50 and may have an impact on the risk/benefit relationship of treatments given 51 .…”

Drug therapy in elderly heart failure patients

“…There are some clinical scenarios that are more common in elderly patients with HF, and which require clinical experience, a watchful approach and early identification of side effects ( Table 1 ). Many comorbidities, including anorexia, 23 iron deficiency, 24 , 25 muscle wasting, 26–28 and frailty 29–31 are all more common in the elderly 32 , 33 making drug side-effects 34 and poor response to therapy more likely. The majority of drugs used in HF, through a variety of mechanisms, may increase the risk of delirium, cognitive impairment, and depression, which may be difficult to distinguish from functional deficits due to cerebrovascular events.…”

Heart failure management of the elderly patient: focus on frailty, sarcopaenia, cachexia, and dementia: conclusions

“…Among older HF patients, women and comorbidities predominate, including hypertension, 9 diabetes, 10 lung disease, 11 coronary disease, 12 renal failure, 13 sleep disordered breathing, 14 , 15 anaemia, 16 and iron deficiency predominate 17 . The older patient, in addition to not being in the trials, is often more prone to polypharmacy, medication errors, and side effects 18 . Factors such as dementia and cognitive decline, anorexia, 19 muscle wasting, 20–22 and frailty 23–25 all of which more common in the elderly 26 may impact on the risk/benefit of treatment given 27 .…”

“…For such patients, elderly with HFpEF there is no established life-saving therapy at all, and the therapeutic strategy is focused on control of HF symptoms and treatment of comorbidities 9 , 12 , 32 . In addition many confounding comorbidities make treatment more difficult; these include iron deficiency, 33 muscle wasting, 20 , 21 and frailty, many making drug side effects 18 more likely. Although we are beginning to address the specific problems of drug therapy in the elderly, much remains left to do to improve the quality and appropriateness of our care in this vulnerable group 34 such as by planning specific care plans for older or frail HF patients 35 …”