Unravelling the interplay between hyperkalaemia, renin–angiotensin–aldosterone inhibitor use and clinical outcomes. Data from 9222 chronic heart failure patients of the ESC‐HFA‐EORP Heart Failure Long‐Term Registry

Rossignol, Patrick; Lainščak, Mitja; Crespo-Leiro, María G.; Laroche, Cécile; Piepoli, Massimo F; Filippatos, Gerasimos; Rosano, Giuseppe; Savarese, Gianluigi; Anker, Stefan D.; Seferović, Petar; Ruschitzka, Frank; Coats, Andrew J.S.; Mebazaa, Alexandre; McDonagh, Theresa A.; Sahuquillo, Ana; Penco, María; Maggioni, Aldo P.; Lund, Lars H.

doi:10.1002/ejhf.1793

Cited by 101 publications

(93 citation statements)

References 34 publications

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“…61,62 Despite a lack of randomized controlled trial data to document improved clinical outcomes with correction of hyperkalemia and reinitiation of RAASi therapy in patients with an increased hyperkalemia risk, there is an increasing body of real-world evidence of increased morbidity and mortality among patients with CKD, HF, or diabetes who receive suboptimal or no RAASi therapy because of hyperkalemia. [63][64][65] For example, in a cohort study of patients who experienced a decline in eGFR to less than 30 mL/min per 1.73 m 2 while receiving RAASi therapy, discontinuation of RAASi therapy was associated with a higher risk of mortality or major adverse cardiovascular events than continuation of RAA-Sis. 63 In addition, a recent consensus report 9 and a position paper 66 suggest that treatment with the newer K þ binders (discussed subsequently) may allow for optimization of RAASi therapy in patients with HF.…”

Section: Risk Factorsmentioning

confidence: 99%

Clinical Management of Hyperkalemia

Palmer

Carrero

Clegg

et al. 2021

Mayo Clinic Proceedings

124

106

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Hyperkalemia is an electrolyte abnormality with potentially life-threatening consequences. Despite various guidelines, no universally accepted consensus exists on best practices for hyperkalemia monitoring, with variations in precise potassium (K þ) concentration thresholds or for the management of acute or chronic hyperkalemia. Based on the available evidence, this review identifies several critical issues and unmet needs with regard to the management of hyperkalemia. Real-world studies are needed for a better understanding of the prevalence of hyperkalemia outside the clinical trial setting. There is a need to improve effective management of hyperkalemia, including classification and K þ monitoring, when to reinitiate previously discontinued renin-angiotensin-aldosterone system inhibitor (RAASi) therapy, and when to use oral K þ-binding agents. Monitoring serum K þ should be individualized; however, increased frequency of monitoring should be considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia and for those receiving RAASi therapy. Recent clinical studies suggest that the newer K þ binders (patiromer sorbitex calcium and sodium zirconium cyclosilicate) may facilitate optimization of RAASi therapy. Enhancing the knowledge of primary care physicians and internists with respect to the safety profiles of these newer K þ binders may increase confidence in managing patients with hyperkalemia. Lastly, the availability of newer K þ-binding agents requires further study to establish whether stringent dietary K þ restrictions are needed in patients receiving K þ-binder therapy. Individualized monitoring of serum K þ among patients with an increased risk of hyperkalemia and the use of newer K þ-binding agents may allow for optimization of RAASi therapy and more effective management of hyperkalemia.

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Section: Risk Factorsmentioning

confidence: 99%

Clinical Management of Hyperkalemia

Palmer

Carrero

Clegg

et al. 2021

Mayo Clinic Proceedings

124

106

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“…After adjusting for a wide range of clinical predictors, and NT‐proBNP, the elevation in risk for death associated with higher potassium was modest and less pronounced than in hypokalaemia. Although prior studies have suggested that the elevated risk for death associated with hyperkalaemia may reflect underdosing or even the withholding of RAAS blockers, 22,23 this is not likely to represent the explanation in the present trial given that patients started on the maximum dose of the study drug and every effort was made to maintain the optimal dose during follow‐up. Moreover, the associations between higher potassium and fatal outcomes were similar for all subtypes of death examined, including non‐CV death, which suggests a lack of any specific mechanistic direct effect of hyperkalaemia.…”

Section: Discussionmentioning

confidence: 82%

Serum potassium in the PARADIGM‐HF trial

Ferreira

Mogensen

Jhund

et al. 2020

European J of Heart Fail

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Aims The associations between potassium level and outcomes, the effect of sacubitril–valsartan on potassium level, and whether potassium level modified the effect of sacubitril–valsartan in patients with heart failure and a reduced ejection fraction were studied in PARADIGM‐HF. Several outcomes, including cardiovascular death, sudden death, pump failure death, non‐cardiovascular death and heart failure hospitalization, were examined. Methods and results A total of 8399 patients were randomized to either enalapril or sacubitril–valsartan. Potassium level at randomization and follow‐up was examined as a continuous and categorical variable (≤3.5, 3.6–4.0, 4.1–4.9, 5.0–5.4 and ≥5.5 mmol/L) in various statistical models. Hyperkalaemia was defined as K+ ≥5.5 mmol/L and hypokalaemia as K+ ≤3.5 mmol/L. Compared with potassium 4.1–4.9 mmol/L, both hypokalaemia [hazard ratio (HR) 2.40, 95% confidence interval (CI) 1.84–3.14] and hyperkalaemia (HR 1.42, 95% CI 1.10–1.83) were associated with a higher risk for cardiovascular death. However, potassium abnormalities were similarly associated with sudden death and pump failure death, as well as non‐cardiovascular death and heart failure hospitalization. Sacubitril–valsartan had no effect on potassium overall. The benefit of sacubitril–valsartan over enalapril was consistent across the range of baseline potassium levels. Conclusions Although both higher and lower potassium levels were independent predictors of cardiovascular death, potassium abnormalities may mainly be markers rather than mediators of risk for death.

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“…L'étude d'un large registre de 9 222 patients de 31 pays différents [17], montre une prévalence de l'hyperkaliémie de 16,6 %. L'hyperkaliémie et l'hypokaliémie étaient un risque de mortalité.…”

Section: Discussionunclassified

Assessment of the population at risk of hyperkalemia

Berrut

Boureau

Decker

et al. 2020

Gériatrie Et Psychologie Neuropsychiatrie Du Viellissement

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Le potassium est un ion essentiel pour le fonctionnement cellulaire, il détermine le voltage et l'excitabilité des myocytes. Son homéostasie est dépendante de l'apport alimentaire et de son élimination rénale prédominante. Le système rénine angiotensinealdostérone (SRAA) en régule l'élimination. L'hyperkaliémie aiguë et chronique est un facteur de risque de mortalité d'origine cardiaque. L'insuffisance rénale chronique et l'insuffisance cardiaque sont les principales comorbidités. Les traitements inhibiteurs du SRAA sont les principaux facteurs iatrogéniques de l'hyperkaliémie. Environ 90 % des patients qui présentent une hyperkaliémie ont plus de 50 ans et 43 % ont plus de 75 ans. Seuls 4,9 % des hyperkaliémies ont une prise en charge thérapeutique par résines. Un tiers des patients ont 3 comorbidités, et 14 % ont 5 comorbidités ou plus. Les principales comorbidités sont une hypertension artérielle (74,0 %), une dyslipidémie (56,3 %), une insuffisance rénale (55,2 %), un diabète (44,7 %), une maladie coronarienne telle que l'angor et l'infarctus du myocarde (23,3 %) et une insuffisance cardiaque (12 %). Il est à noter que les deux tiers des patients recevant des résines, recevaient également des ISRAA et présentaient une tendance à avoir plus de comorbidités. L'hyperkaliémie est sous-estimée et nécessite une surveillance stricte chez les patients présentant une insuffisance rénale ou une insuffisance cardiaque. Les résines ne sont pas adaptées à une bonne observance au long cours et de nouveaux traitements tels que le patiromer, permettraient de réduire le risque d'hyperkaliémie.

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Unravelling the interplay between hyperkalaemia, renin–angiotensin–aldosterone inhibitor use and clinical outcomes. Data from 9222 chronic heart failure patients of the ESC‐HFA‐EORP Heart Failure Long‐Term Registry

Cited by 101 publications

References 34 publications

Clinical Management of Hyperkalemia

Clinical Management of Hyperkalemia

Serum potassium in the PARADIGM‐HF trial

Assessment of the population at risk of hyperkalemia

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