A propensity-matched study of the association of low serum potassium levels and mortality in chronic heart failure

Investigating the Relationship Between Lipid-Lowering Agents and the Complications of Diabetic Retinopathy

BACKGROUND AND OBJECTIVE

As the therapeutic efficacy of lipid-lowering agents (LLA) against diabetic retinopathy (DR) remains controversial, this study aimed to evaluate whether various LLA therapies are associated with a reduced risk of DR progression.

PATIENTS AND METHODS

This retrospective study of the medical records of adults with type 2 diabetes mellitus and DR compared the risk of adverse progression of DR between patients who received statins, fibrates, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, and no LLA (control).

RESULTS

Patients in the statin cohort had a reduced rate of progression to proliferative DR compared to controls (HR = 0.30, CI = 0.11 to 0.83). The PCSK9 inhibitor cohort had a reduced risk of progressing to other secondary complications of DR compared to the control (RR = 0.52, CI = 0.43 to 0.64), statin (RR = 0.69, CI = 0.61 to 0.79), and fibrate (RR = 0.67, CI = 0.59 to 0.77) cohorts.

CONCLUSIONS

These findings suggest use of statins and PCSK9 inhibitors are associated with a reduced risk of adverse progression of DR. [Ophthalmic Surg Lasers Imaging Retina 2024;55:XX-XX.].

Artificial intelligence approaches for phenotyping heart failure in U.S. Veterans Health Administration electronic health record

AIMS

Heart failure (HF) is a clinical syndrome with no definitive diagnostic tests. HF registries are often based on manual reviews of medical records of hospitalized HF patients identified using International Classification of Diseases (ICD) codes. However, most HF patients are not hospitalized, and manual review of big electronic health record (EHR) data is not practical. The US Department of Veterans Affairs (VA) has the largest integrated healthcare system in the nation, and an estimated 1.5 million patients have ICD codes for HF (HF ICD-code universe) in their VA EHR. The objective of our study was to develop artificial intelligence (AI) models to phenotype HF in these patients.

METHODS AND RESULTS

The model development cohort (n = 20 000: training, 16 000; validation 2000; testing, 2000) included 10 000 patients with HF and 10 000 without HF who were matched by age, sex, race, inpatient/outpatient status, hospital, and encounter date (within 60 days). HF status was ascertained by manual chart reviews in VA's External Peer Review Program for HF (EPRP-HF) and non-HF status was ascertained by the absence of ICD codes for HF in VA EHR. Two clinicians annotated 1000 random snippets with HF-related keywords and labelled 436 as HF, which was then used to train and test a natural language processing (NLP) model to classify HF (positive predictive value or PPV, 0.81; sensitivity, 0.77). A machine learning (ML) model using linear support vector machine architecture was trained and tested to classify HF using EPRP-HF as cases (PPV, 0.86; sensitivity, 0.86). From the 'HF ICD-code universe', we randomly selected 200 patients (gold standard cohort) and two clinicians manually adjudicated HF (gold standard HF) in 145 of those patients by chart reviews. We calculated NLP, ML, and NLP + ML scores and used weighted F scores to derive their optimal threshold values for HF classification, which resulted in PPVs of 0.83, 0.77, and 0.85 and sensitivities of 0.86, 0.88, and 0.83, respectively. HF patients classified by the NLP + ML model were characteristically and prognostically similar to those with gold standard HF. All three models performed better than ICD code approaches: one principal hospital discharge diagnosis code for HF (PPV, 0.97; sensitivity, 0.21) or two primary outpatient encounter diagnosis codes for HF (PPV, 0.88; sensitivity, 0.54).

CONCLUSIONS

These findings suggest that NLP and ML models are efficient AI tools to phenotype HF in big EHR data to create contemporary HF registries for clinical studies of effectiveness, quality improvement, and hypothesis generation.

Prevalence and prognostic value of electrocardiographic abnormalities in hypokalemia: A multicenter cohort study

BACKGROUND

Hypokalemia is common in hospitalized patients and associated with ECG abnormalities. The prevalence and prognostic value of ECG abnormalities in hypokalemic patients are, however, not well established.

METHODS

The study was a multicentered cohort study, including all ault patients with an ECG and potassium level <4.4 mmol/L recorded at arrival to four emergency departments in Denmark and Sweden. Using computerized measurements from ECGs, we investigated the relationship between potassium levels and heart rate, QRS duration, corrected QT (QTc) interval, ST-segment depressions, T-wave flattening, and T-wave inversion using cubic splines. Within strata of potassium levels, we further estimated the hazard ratio (HR) for 7-day mortality, admission to the intensive care unit (ICU), and diagnosis of ventricular arrhythmia or cardiac arrest, comparing patients with and without specific ECG abnormalities matched 1:2 on propensity scores.

RESULTS

Among 79,599 included patients, decreasing potassium levels were associated with a concentration-dependent increase in all investigated ECG variables. ECG abnormalities were present in 40% of hypokalemic patients ([K+ ] <3.5 mmol/L), with T-wave flattening, ST-segment depression, and QTc prolongation occurring in 27%, 16%, and 14%. In patients with mild hypokalemia ([K+ ] 3.0-3.4 mmol/L), a heart rate >100 bpm, ST-depressions, and T-wave inversion were associated with increased HRs for 7-day mortality and ICU admission, whereas only a heart rate >100 bpm predicted both mortality and ICU admission among patients with [K+ ] <3.0 mmol/L. HR estimates were, however, similar to those in eukalemic patients. The low number of events with ventricular arrhythmia limited evaluation for this outcome.

CONCLUSIONS

ECG abnormalities were common in hypokalemic patients, but they are poor prognostic markers for short-term adverse events under the current standard of care.

Potassium levels and the risk of all-cause and cardiovascular mortality among patients with cardiovascular diseases: a meta-analysis of cohort studies

BACKGROUND

Abnormal blood potassium levels are associated with an increased risk of cardiometabolic diseases and mortality in the general population; however, evidence regarding the association between dyskalemia and mortality among patients with cardiovascular disease (CVD) remains inconclusive. This study aimed to evaluate the association of potassium levels with all-cause and cardiovascular mortality among patients with CVD.

METHODS

PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to August 2023 to identify relevant cohort studies among patients with CVD, such as myocardial infarction, stroke, and heart failure. Abnormal potassium levels were considered as hypokalemia or hyperkalemia. The primary outcomes were all-cause mortality based on follow-up length (including in-hospital, short-term and long-term mortality) and cardiovascular mortality. The methodological quality of included studies was assessed by using the Newcastle-Ottawa Scale. The pooled relative risks (RRs) and 95% confidence intervals (CIs) were calculated using random-effects models. Restricted cubic splines were applied to explore the dose-response relationship.

RESULTS

Thirty-one cohort studies involving 227,645 participants with an average age of 68.3 years were included in the meta-analysis, all of which achieved moderate to high quality. Hyperkalemia was significantly associated with an approximately 3.0-fold increased risk of all-cause in-hospital mortality (RR:2.78,95CI%:1.92,4.03), 1.8-fold of all-cause short-term mortality (RR:1.80, 95CI%:1.44,2.27), 1.3-fold of all-cause long-term mortality (RR:1.33, 95CI%:1.19,1.48) and 1.2-fold of cardiovascular mortality (RR:1.19, 95CI%:1.04,1.36). Similar positive associations were also observed between hypokalemia and risk of all-cause mortality and cardiovascular mortality. The RRs of all-cause in-hospital, short-term, long-term mortality and cardiovascular mortality with hyperkalemia were attenuated to 2.21 (95CI%:1.60,3.06), 1.46(95CI%:1.25,1.71), 1.23 (95CI%:1.09,1.39) and 1.13 (95CI%:1.00,1.27) when treating hypokalemia together with normokalemia as the reference group. A U-shaped association was observed between potassium levels and mortality, with the lowest risk at around 4.2 mmol/L.

CONCLUSIONS

Both hypokalemia and hyperkalemia were positively associated with the risk of mortality in patients with CVD. Our results support the importance of potassium homeostasis for improving the CVD management.

REGISTRATION

PROSPERO, CRD42022324337.

Short-term prognosis of changes in plasma potassium following an episode of hyperkalaemia in patients with chronic heart failure

BACKGROUND/AIM

There is an increasing prevalence of chronic heart failure (HF). It is well known that patients with HF and disturbances in the potassium level have an increased mortality risk. The aim of this study was to investigate the prognosis of a second plasma-potassium measurement after an episode with hyperkalaemia on short-term mortality in patients with chronic HF.

METHODS AND RESULTS

From Danish national registers, 2,339 patients with chronic HF and hyperkalaemia (>4.6 mmol/L) at first potassium measurement within 14-365 days from concomitant treatment were identified. To be included, a second measurement was required within 6-30 days subsequent to the first measurement and the 60-day mortality was observed. Based on the second measurement, the patients were divided into five groups: <3.5 mmol/L (n = 257), 3.5-4.0 mmol/L (n = 709), 4.1-4.6 mmol/L (n = 1,204, reference), 4.7-5.0 mmol/L (n = 89) and >5.0 mmol/L (n = 80). To assess all-cause and cardiovascular mortality, we used the Cox regression model. The multivariable analysis showed that patients with potassium concentrations <3.5 mmol/L (hazard ratio (HR): 3.03; 95% CI: 2.49-3.70) and 3.5-4.0 mmol/L (HR: 1.81; 95% CI: 1.54-2.14) had a worse prognosis compared to the reference. We observed similar results when calculating the risk of cardiovascular mortality. A restricted cubic spline curve showed a U-shaped relationship between plasma-potassium and all-cause mortality.

CONCLUSION

Patients with chronic HF and hyperkalaemia who became hypokalaemic after 6-30 days were associated with a higher 60-day all-cause and cardiovascular mortality compared to the reference. This also applied for patients with low normal potassium concentrations (3.5-4.0 mmol/L).

Serum Potassium Levels and Mortality in Hospitalized Heart Failure Patients

Background

To assess the link between serum potassium ( K + ) and all-cause mortality in hospitalized heart failure (HF) patients.

Methods

Hospitalized HF patients (n = 3114) were analyzed at the Fuwai Hospital Heart Failure Center. Before discharge, HF patients were divided into four groups according to the K + level quartiles: K + ≤ 3.96 mmol/L (Q1), 3.96 < K + ≤ 4.22 mmol/L (Q2), 4.22 < K + ≤ 4.52 mmol/L (Q3), and K + > 4.52 mmol/L (Q4). At 90 days, 2 years, and maximal follow-up, all-cause mortality was the primary outcome.

Results

Patients with HF in the Q4 group had worse cardiac function, higher N-terminal pro-B-type natriuretic peptide levels, lower left ventricular ejection fractions and lower estimated glomerular filtration rates than patients in the Q2 group. In the multivariate-adjusted Cox analysis, the mortality assessed during the 90-day, 2-year, and maximal follow-up examinations increased in the Q4 group of HF patients but not in the Q1 and Q3 groups. The Q4 group had a 28% (hazard ratio [HR]: 1.28, 95% confidence interval [CI]: 1.09-1.49, p = 0.002) higher risk of all-cause mortality at maximum follow-up. Hypokalemia and hyperkalemia were linked to increased HF mortality risk at the 90-day, 2-year, and maximal follow-up periods.

Conclusions

Serum K + levels had a J-shaped association with all-cause mortality in HF patients. Both hypokalemia and a K + level of > 4.52 mmol/L were associated with increased all-cause mortality in the short term and long term, suggesting a narrow target K + range in HF patients.

Clinical Trial Registration

Unique Identifier: NCT02664818; URL: clinicaltrials.gov.

Diagnosis and Management of Malnutrition in Patients with Heart Failure

Heart failure is a disease with an increasingly greater prevalence due to the aging population, the development of new drugs, and the organization of healthcare processes. Malnutrition has been identified as a poor prognostic factor in these patients, very often linked to frailty or to other comorbidities, meaning that early diagnosis and treatment are essential. This paper reviews some important aspects of the pathophysiology, detection, and management of malnutrition in patients with heart failure.

Interpretable machine learning prediction of all-cause mortality

Background

Unlike linear models which are traditionally used to study all-cause mortality, complex machine learning models can capture non-linear interrelations and provide opportunities to identify unexplored risk factors. Explainable artificial intelligence can improve prediction accuracy over linear models and reveal great insights into outcomes like mortality. This paper comprehensively analyzes all-cause mortality by explaining complex machine learning models.

Methods

We propose the IMPACT framework that uses XAI technique to explain a state-of-the-art tree ensemble mortality prediction model. We apply IMPACT to understand all-cause mortality for 1-, 3-, 5-, and 10-year follow-up times within the NHANES dataset, which contains 47,261 samples and 151 features.

Results

We show that IMPACT models achieve higher accuracy than linear models and neural networks. Using IMPACT, we identify several overlooked risk factors and interaction effects. Furthermore, we identify relationships between laboratory features and mortality that may suggest adjusting established reference intervals. Finally, we develop highly accurate, efficient and interpretable mortality risk scores that can be used by medical professionals and individuals without medical expertise. We ensure generalizability by performing temporal validation of the mortality risk scores and external validation of important findings with the UK Biobank dataset.

Conclusions

IMPACT's unique strength is the explainable prediction, which provides insights into the complex, non-linear relationships between mortality and features, while maintaining high accuracy. Our explainable risk scores could help individuals improve self-awareness of their health status and help clinicians identify patients with high risk. IMPACT takes a consequential step towards bringing contemporary developments in XAI to epidemiology.

Incidence and Determinants of Piperacillin/Tazobactam-Associated Hypokalemia: A Retrospective Study

Piperacillin/tazobactam (TZP) is a commonly used antibiotic for treating moderate-to-severe infections because of its broad-spectrum activity and recommendation as an alternative to carbapenem. TZP-associated severe hypokalemia has been consistently reported; however, related studies are very rare. This study aimed to evaluate the incidence and risk factors of TZP-associated hypokalemia (TAH). A retrospective cohort study was conducted on hospitalized adult patients who received TZP from 1 January 2015 to 31 December 2017 at a tertiary teaching hospital. Of the 713 patients, 13.9% had TAH. As a result of multivariate logistic regression analysis, older age (OR 1.03, 95% CI: 1.02−1.05, p < 0.001), female sex (OR 1.88, 95% CI: 1.18−3.00, p = 0.008), longer duration of TZP therapy (OR 1.08, 95% CI: 1.04−1.13, p < 0.001), and higher TZP daily dose (OR 1.10, 95% CI: 1.01−1.20, p = 0.049) were independently associated with TAH. In contrast, higher baseline serum potassium level (OR 0.13, 95% CI: 0.07−0.26, p < 0.001) was related to lower TAH. Furthermore, hypokalemia mostly occurred in the early days of TZP therapy (median onset time: 4 days). Thus, close monitoring of serum potassium levels, especially upon therapy initiation, is essential to prevent TAH.

Value of FT3/FT4 Ratio in Prognosis of Patients With Heart Failure: A Propensity-Matched Study

Aims

Abnormal thyroid hormone secretions can alter the manifestation and prognosis of cardiovascular disease. To assess the effect of the free triiodothyronine (FT3)/free thyroxine (FT4) ratio on the prognosis of patients with heart failure (HF), we performed a propensity-matched study on patients with well-balanced baseline characteristics.

Methods

Overall, 8,887 patients with HF were divided into two groups according to the FT3/FT4 ratio. Propensity scores were calculated from each patient. A cohort comprising 2,164 pairs with high or low ratios and with 34 well-balanced baseline characteristics was then assembled. The endpoints were Cardiovascular (CV) mortality and all-cause mortality. The correlation between FT3/FT4 ratio and prognosis was assessed using matched Cox regression analyses. The mean follow-up was 3.3 years.

Results

In the full pre-match cohort, 3,710 (41.7%) patients died, with 2,581 (29.0%) cases of CV mortality. In the matched-pair cohort, all-cause mortality occurred in 923 (1,238/10,000 person-years of follow-up) patients with a high ratio and 1,036 (1,484/10,000 person-years) patients with a low ratio, resulting in a matched HR of 0.841 (95% CI: 0.769-0.919; P < 0.001). For CV mortality, the result was 638 (856/10,000 person-years) and 714 (1,023/10,000 person-years) patients, respectively, resulting in a matched HR of 0.844 (95% CI: 0.759-0.940; P < 0.001). Subgroup analysis revealed that a low FT3/FT4 ratio had a greater predictive value for all-cause and CV mortality in elderly or male patients and in patients with coronary artery disease (CAD), hypertension, diabetes mellitus, HFmrEF, or HFpEF.

Conclusions

A low FT3/FT4 ratio is valuable for predicting CV mortality and all-cause mortality in patients with HF.

2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC

Document Reviewers: Rudolf A. de Boer (CPG Review Coordinator) (Netherlands), P. Christian Schulze (CPG Review Coordinator) (Germany), Magdy Abdelhamid (Egypt), Victor Aboyans (France), Stamatis Adamopoulos (Greece), Stefan D. Anker (Germany), Elena Arbelo (Spain), Riccardo Asteggiano (Italy), Johann Bauersachs (Germany), Antoni Bayes-Genis (Spain), Michael A. Borger (Germany), Werner Budts (Belgium), Maja Cikes (Croatia), Kevin Damman (Netherlands), Victoria Delgado (Netherlands), Paul Dendale (Belgium), Polychronis Dilaveris (Greece), Heinz Drexel (Austria), Justin Ezekowitz (Canada), Volkmar Falk (Germany), Laurent Fauchier (France), Gerasimos Filippatos (Greece), Alan Fraser (United Kingdom), Norbert Frey (Germany), Chris P. Gale (United Kingdom), Finn Gustafsson (Denmark), Julie Harris (United Kingdom), Bernard Iung (France), Stefan Janssens (Belgium), Mariell Jessup (United States of America), Aleksandra Konradi (Russia), Dipak Kotecha (United Kingdom), Ekaterini Lambrinou (Cyprus), Patrizio Lancellotti (Belgium), Ulf Landmesser (Germany), Christophe Leclercq (France), Basil S. Lewis (Israel), Francisco Leyva (United Kingdom), AleVs Linhart (Czech Republic), Maja-Lisa Løchen (Norway), Lars H. Lund (Sweden), Donna Mancini (United States of America), Josep Masip (Spain), Davor Milicic (Croatia), Christian Mueller (Switzerland), Holger Nef (Germany), Jens-Cosedis Nielsen (Denmark), Lis Neubeck (United Kingdom), Michel Noutsias (Germany), Steffen E. Petersen (United Kingdom), Anna Sonia Petronio (Italy), Piotr Ponikowski (Poland), Eva Prescott (Denmark), Amina Rakisheva (Kazakhstan), Dimitrios J. Richter (Greece), Evgeny Schlyakhto (Russia), Petar Seferovic (Serbia), Michele Senni (Italy), Marta Sitges (Spain), Miguel Sousa-Uva (Portugal), Carlo G. Tocchetti (Italy), Rhian M. Touyz (United Kingdom), Carsten Tschoepe (Germany), Johannes Waltenberger (Germany/Switzerland) All experts involved in the development of these guidelines have submitted declarations of interest. These have been compiled in a report and published in a supplementary document simultaneously to the guidelines. The report is also available on the ESC website www.escardio.org/guidelines For the Supplementary Data which include background information and detailed discussion of the data that have provided the basis for the guidelines see European Heart Journal online.

Hyperchloremia is associated with poor renal outcome after coronary artery bypass grafting

Background

Hyperchloremia is associated with the risks of several morbidities and mortality. However, its relationship with acute kidney injury (AKI) and end-stage renal disease (ESRD) in patients undergoing coronary artery bypass grafting (CABG) remains unresolved.

Methods

A total of 2977 patients undergoing CABG between 2003 and 2015 were retrospectively reviewed from two tertiary hospitals. Patients were categorized by serum chloride levels into normochloremia (95–105 mmol/L), mild hyperchloremia (106–110 mmol/L), and severe hyperchloremia (> 110 mmol/L). The odds ratios (ORs) for AKI and hazard ratios (HRs) for ESRD were calculated after adjustment for multiple covariates. The death-adjusted risk of ESRD was additionally evaluated.

Results

Postoperative AKI occurred in 798 patients (26.5%). The hyperchloremia group had a higher risk of AKI than the normochloremia group, wherein the risk was incremental depending on the severity of hyperchloremia, as follows: ORs were 1.26 (1.06–1.51) and 1.95 (1.52–2.51) in the mild and severe hyperchloremia groups, respectively. During a median period of 7 years (maximum 15 years), 70 patients (2.3%) had ESRD. The severe hyperchloremia group was at an elevated risk of ESRD compared with the normochloremia group, with an HR of 2.43 (1.28–4.63). Even after adjusting for the competing risk of death, hyperchloremia was associated with the risk of ESRD.

Conclusions

Preoperative hyperchloremia is associated with poor renal outcomes such as AKI and ESRD after CABG. Accordingly, serum chloride should be monitored in patients undergoing CABG.

Association between serum potassium and risk of all-cause mortality among chronic kidney diseases patients: A systematic review and dose-response meta-analysis of more than one million participants

We aimed to perform a meta-analysis, using prospective cohort studies, to test the association between serum potassium and all-cause mortality among chronic kidney diseases (CKD) patients. A systematic search was performed using PubMed-MEDLINE and Scopus, up to July 2020. Prospective cohort studies which reported risk estimates of all-cause mortality in CKD patients with different serum potassium levels were included in the present meta-analysis. Thirteen studies were included in the analysis. A nonlinear dose-response meta-analysis suggested that there is a J-shaped association between serum potassium levels and the risk of all-cause mortality, with a nadir at serum potassium of 4.5 mmol/L. Subgroup analyses indicated that the strength and shape of the association between serum potassium and all-cause mortality may be influenced by age. Our meta-analysis provides supportive evidence that there is a J-shape association between serum potassium and all-cause mortality among CKD patients.

Retrospective evaluation of a dose-dependent effect of angiotensin-converting enzyme inhibitors on long-term outcome in dogs with cardiac disease

Background

Angiotensin‐converting enzyme inhibitors (ACEIs) are commonly prescribed in dogs, but the ideal dosage is unknown.

Hypothesis/Objectives

In dogs with cardiac disease, a dose‐response relationship exists for ACEIs with respect to long‐term outcome.

Animals

One hundred forty‐four dogs with cardiac disease, 63 with current or prior congestive heart failure.

Methods

Retrospective medical record review. Cox proportional hazards models were used to determine variables associated with 2‐year survival or survival from first‐onset congestive heart failure (CHF).

Results

Median initial ACEI dosage was 0.84 (interquartile range [IQR], 0.56‐0.98) mg/kg/day, and 108/144 (75%) of dogs received q12h dosing. No clinically relevant changes in renal function test results, serum electrolyte concentrations, or blood pressure occurred between initial prescription of ACEI and first reevaluation (median, 14 days later). In univariable analysis, higher ACEI dose was associated with increased survival from first‐onset CHF (P = .005), and within the subgroup of dogs in CHF at the time of ACEI prescription, higher ACEI dose was associated with improved survival at 2 years (P = .04). In multivariable analysis, q12h dose frequency of ACEI (hazard ratio [HR], 0.30; 95% CI, 0.10‐0.88; P = .03) and higher serum potassium concentration at visit 1 (HR, 0.39; 95% CI, 0.16‐0.97; P = .04) were predictive of 2‐year survival. The ACEIs were well‐tolerated, with only 8/144 (5.6%) dogs having ACEI dose decreased or discontinued because of adverse effects.

Conclusions and Clinical Importance

Twice daily dose frequency might optimize the cardioprotective benefit of ACEIs.

Development of a preoperative index-based nomogram for the prediction of hypokalemia in patients with pituitary adenoma: a retrospective cohort study

Objective

To develop and validate a preoperative index-based nomogram for the prediction of hypokalemia in patients with pituitary adenoma (PA).

Methods

This retrospective cohort study included 205 patients with PAs between January 2013 and April 2020 in the Sun Yat-sen Memorial Hospital, Guangzhou, China. The patients were randomly classified into either a training set (N = 143 patients) and a validation set (N = 62 patients) at a ratio of 7:3. Variables, which were identified by using the LASSO regression model were included for the construction of a nomogram, and a logistic regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) in the training set. The area under the curve (AUC) was used to evaluate the performance of the nomogram for predicting hypokalemia. Multivariate logistic regression analysis with a restricted cubic spline analysis was conducted to identify a potential nonlinear association between the preoperative index and hypokalemia.

Results

The incidence of hypokalemia was 38.05%. Seven preoperative indices were identified for the construction of the nomogram: age, type of PA, weight, activated partial thromboplastin time, urea, eosinophil percentage, and plateletocrit. The AUCs of the nomogram for predicting hypokalemia were 0.856 (95% CI [0.796–0.915]) and 0.652 (95% CI [0.514–0.790]) in the training and validation sets, respectively. Restricted cubic splines demonstrated that there was no nonlinear association between hypokalemia and the selected variables.

Conclusion

In this study, we constructed a preoperative indices-based nomogram that can assess the risk of hypokalemia after the surgical treatment of pituitary adenomas. This nomogram may also help to identify high risk patients who require close monitoring of serum potassium.

Using MoS2/Fe3O4 as Ion-Electron Transduction Layer to Manufacture All-Solid-State Ion-Selective Electrode for Determination of Serum Potassium

As an essential electrolyte for the human body, the potassium ion (K+) plays many physiological roles in living cells, so the rapid and accurate determination of serum K+ is of great significance. In this work, we developed a solid-contact ion-selective electrode (SC-ISE) using MoS2/Fe3O4 composites as the ion-to-electron transducer to determine serum K+. The potential response measurement of MoS2/Fe3O4/K+-ISE shows a Nernst response by a slope of 55.2 ± 0.1 mV/decade and a low detection limit of 6.3 × 10−6 M. The proposed electrode exhibits outstanding resistance to the interference of O2, CO2, light, and water layer formation. Remarkably, it also presents a high performance in potential reproducibility and long-term stability.

A 5-Year Survival Prediction Model for Chronic Heart Failure Patients Induced by Coronary Heart Disease with Traditional Chinese Medicine Intervention

Objective

This study aimed to construct a 5-year survival prediction model of coronary heart disease (CHD) induced chronic heart failure (CHF), which is supported by the traditional Chinese medicine (TCM) factor, and to verify the model.

Methods

Inpatients from January 1, 2012, to December 31, 2017, in seven hospitals in Shandong Province were studied. The random number table was used to randomly divide the seven hospitals into two groups (training set and verification set). In the training set, the least absolute shrinkage selection operator regression was first used to screen the independent variables. Logistic regression was then applied to construct a survival prediction model. The following nomogram visualizes the prediction model results. Finally, C-indices, calibration curves, and decision curves were used to discriminate and calibrate the established model and evaluate its practicability in the clinic. Bootstrap resampling and the verification set were used for internal and external verification, respectively.

Results

A total of 424 eligible patients were included in the model construction and verification. In this 5-year survival prediction model of patients with CHF induced by CHD, eight independent predictors were included. The series of C-indices for the training set, bootstrap resamples, and verification set was 0.885, 0.867, and 0.835, respectively, demonstrating the credibility of our model. Additionally, the receiver operating characteristic curve, calibration curve, and clinical decision curve analysis of the training and verification sets showed that this 5-year survival prediction model was good in discrimination, calibration, and clinical practicability.

Conclusion

This work highlights eight independent factors affecting 5-year mortality in patients with CHF induced by CHD after discharge and further helps reallocate medical resources rationally by precisely identifying high-risk groups. The constructed prediction model not only plays a credible role in prediction but also demonstrates TCM intervention as a protective factor for the 5-year death of patients with CHF induced by CHD, thereby advancing the use of TCM in CHF.

Comparative risk assessment of non-communicable diseases by evacuation scenario- a retrospective study in the 7 years following the Fukushima Daiichi nuclear power plant accident

Background: As a result of the Fukushima Daiichi nuclear power plant accident, many residents evacuated and were exposed to changes in their living environment and socioeconomic status, and to persistent stressors. Past studies have suggested the potential for these circumstances to contribute to long-term changes to population health.Objective: The objective of this study was to gain a better understanding of long-term health effects of evacuation, by evaluating the risk of non-communicable diseases among evacuees from Minamisoma City (one of the closest municipalities to the power plant) until 2017.Methods: The study evaluated data from annual health check-ups for residents aged 40-74 years covered by National Health Insurance (who are largely self-employed) from 2010 to 2017 administered by Minamisoma City. Diabetes, hyperlipidemia, and hypertension were defined from the results of blood sampling. Annual changes in age-adjusted prevalence were estimated by evacuation scenario. We also performed an inverse-probability weighting (IPW) analysis to adjust for baseline covariates in 2010 and estimated the differences in the risk of diabetes, hyperlipidemia, and hypertension by evacuation scenario as of the 2017 health check-up in reference to the no-evacuation group.Results: A total of 1,837 individuals were considered in this study. Regardless of evacuation scenario, there was statistical evidence suggesting an upward and a downward trend in diabetes and hypertension from 2010 to 2017, respectively, while hyperlipidemia showed no remarkable change. IPW analyses demonstrated that disease risks in 2017 did not differ significantly among people with different evacuation scenarios.Conclusions: Region-specific factors played an important role in the health effects of the evacuation. Our findings have important implications for the need of an assessment of the health effects of evacuations in more localized manner. Further research in this area will strengthen the communities' preparedness for future disasters that require mass evacuation.

Loop Diuretic Prescription and Long-Term Outcomes in Heart Failure: Association Modification by Congestion

BACKGROUND

The effect of loop diuretics on clinical outcomes in heart failure has not been evaluated in randomized controlled trials. In hospitalized patients with heart failure, a discharge loop diuretic prescription has been shown to be associated with improved 30-day outcomes, which appears to be more pronounced in subgroups with congestion. In the current study, we examined these associations and association modifications during longer follow-up.

METHODS

We assembled a propensity score-matched cohort of 2191 pairs of hospitalized heart failure patients discharged with, vs without, a prescription for loop diuretics, balanced on 74 baseline characteristics (mean age 78 years; 54% women; 11% African American).

RESULTS

Hazard ratio (HR) and 95% confidence interval (CI) for 6-year combined endpoint of heart failure readmission or all-cause mortality was 1.02 (0.96-1.09). HRs and 95% CIs for this combined endpoint in patients with no, mild-to-moderate, and severe pulmonary rales were 1.19 (1.07-1.33), 0.95 (0.86-1.04), and 0.77 (0.63-0.94), respectively (P for interaction, < .001). Respective HRs (95% CIs) for no, mild-to-moderate, and severe lower extremity edema were 1.16 (1.06-1.28), 0.94 (0.85-1.04), and 0.71 (0.56-0.89; interaction P < .001).

CONCLUSIONS

The association between a discharge loop diuretic prescription and long-term clinical outcomes in hospitalized patients with heart failure is modified by admission congestion with worse, neutral, and better outcomes in patients with no, mild-to-moderate, and severe congestion, respectively. If these findings can be replicated, congestion may be used to risk-stratify patients with heart failure for potential optimization of loop diuretic prescription and outcomes.

Immediate and Delayed Response of Simulated Human Atrial Myocytes to Clinically-Relevant Hypokalemia

Although plasma electrolyte levels are quickly and precisely regulated in the mammalian cardiovascular system, even small transient changes in K⁺, Na⁺, Ca²⁺, and/or Mg²⁺ can significantly alter physiological responses in the heart, blood vessels, and intrinsic (intracardiac) autonomic nervous system. We have used mathematical models of the human atrial action potential (AP) to explore the electrophysiological mechanisms that underlie changes in resting potential (V_r) and the AP following decreases in plasma K⁺, [K⁺]_o, that were selected to mimic clinical hypokalemia. Such changes may be associated with arrhythmias and are commonly encountered in patients (i) in therapy for hypertension and heart failure; (ii) undergoing renal dialysis; (iii) with any disease with acid-base imbalance; or (iv) post-operatively. Our study emphasizes clinically-relevant hypokalemic conditions, corresponding to [K⁺]_o reductions of approximately 1.5 mM from the normal value of 4 to 4.5 mM. We show how the resulting electrophysiological responses in human atrial myocytes progress within two distinct time frames: (i) Immediately after [K⁺]_o is reduced, the K⁺-sensing mechanism of the background inward rectifier current (I_K1) responds. Specifically, its highly non-linear current-voltage relationship changes significantly as judged by the voltage dependence of its region of outward current. This rapidly alters, and sometimes even depolarizes, V_r and can also markedly prolong the final repolarization phase of the AP, thus modulating excitability and refractoriness. (ii) A second much slower electrophysiological response (developing 5-10 minutes after [K⁺]_o is reduced) results from alterations in the intracellular electrolyte balance. A progressive shift in intracellular [Na⁺]_i causes a change in the outward electrogenic current generated by the Na⁺/K⁺ pump, thereby modifying V_r and AP repolarization and changing the human atrial electrophysiological substrate. In this study, these two effects were investigated quantitatively, using seven published models of the human atrial AP. This highlighted the important role of I_K1 rectification when analyzing both the mechanisms by which [K⁺]_o regulates V_r and how the AP waveform may contribute to "trigger" mechanisms within the proarrhythmic substrate. Our simulations complement and extend previous studies aimed at understanding key factors by which decreases in [K⁺]_o can produce effects that are known to promote atrial arrhythmias in human hearts.

Update on management of hypokalemia and goals for the lower potassium level in patients with cardiovascular disease: A review in collaboration with the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy

Hypokalaemia is common in patients with cardiovascular disease. In this review, we emphasize the importance of tight potassium regulation in patients with cardiovascular disease based on findings from observational studies. To enhance the understanding, we also describe the mechanisms of potassium homeostasis maintenance, the most common causes of hypokalaemia and present strategies for monitoring and management of low potassium levels. We propose elevation of potassium in asymptomatic patients with lower normal concentrations and concurrent cardiovascular disease. These proposals are intended to assist clinicians until more evidence is available.

Management of hyperkalemia during treatment with mineralocorticoid receptor blockers: findings from esaxerenone

The nonsteroidal mineralocorticoid receptor (MR) blocker esaxerenone has demonstrated good antihypertensive activity in a variety of patients, including those with uncomplicated grade I-III hypertension, hypertension with moderate renal dysfunction, hypertension with type 2 diabetes mellitus with albuminuria, and hypertension associated with primary aldosteronism. Hyperkalemia has long been recognized as a potential side effect occurring during treatment with MR blockers, but there is a lack of understanding and guidance about the appropriate management of hyperkalemia during antihypertensive therapy with MR blockers, especially in regard to the newer agent esaxerenone. In this article, we first highlight risk factors for hyperkalemia, including advanced chronic kidney disease, diabetes mellitus, cardiovascular disease, age, and use of renin-angiotensin-aldosterone system inhibitors. Next, we examine approaches to prevention and management, including potassium monitoring, diet, and the use of appropriate therapeutic techniques. Finally, we summarize the currently available data for esaxerenone and hyperkalemia. Proper management of serum potassium is required to ensure safe clinical use of MR blockers, including awareness of at-risk patient groups, choosing appropriate dosages for therapy initiation and dosage titration, and monitoring of serum potassium during therapy. It is critical that physicians take such factors into consideration to optimize MR blocker therapy in patients with hypertension.

Dyskalemia: a management problem for students

BACKGROUND

Although dyskalemia is common, its management can be problematic for students and general practitioners, especially when it occurs in patients with heart and renal failure. The basic academic knowledge of general medicine students, who have often not yet encountered clinical situations of dyskalemia, remains unclear in this regard.

OBJECTIVES

The purpose of this study was to evaluate the knowledge and reflexive practices of general medicine students in regard to dyskalemia.

METHODS

A cross-sectional survey, based on a self-questionnaire, of all of the students enrolled in general medicine studies at the Faculty of Medicine at the University of Nancy (France) at the end of their degree. The students were asked questions pertaining to specific clinical situations. The answers were compared to the information provided in the medical curriculum as well as to the relevant European guidelines.

RESULTS

We collected 290 of the questionnaires (participation rate: 81.2%). The hyper- and hypokalemia thresholds considered pathological (3.5-5.0 mmol/L) were known by 78% and 67% of the students, respectively. The perception of danger in case of severe hypokalemia was underestimated by 62.7% of them. In most cases, the proposed management of hyperkalemia in heart and renal failure did not comply with the relevant guidelines. The students tended to favor permanent discontinuation of the administration of converting enzyme inhibitors (ACE) and/or mineralocorticoid receptor antagonists (MRA) without considering the need for their reintroduction (51.6%). Sodium polystyrene sulfate was frequently seen as an appropriate first-line treatment for hyperkalemia (45%).

CONCLUSIONS

The knowledge and competence of general medicine students appear to be lacking for hyperkalemia in heart and renal failure, and they are long way from full compliance with the relevant European guidelines. Exposure to complex clinical situations as part of the medical curriculum, therefore, seems essential to improve the way dyskalemia is managed in France.

Prognostic impact of mineralocorticoid receptor antagonist in patients with heart failure with preserved ejection fraction

AIMS

This study aims to investigate the prognostic impact of mineralocorticoid receptor antagonists (MRAs) on cardiovascular events in patients hospitalized for acute decompensated heart failure with preserved ejection fraction (HFpEF; defined as left ventricular ejection fraction ≥45%).

METHODS AND RESULTS

A prospective multicentre cohort study was conducted in Nagano prefecture, Japan, between July 2014 and December 2018 that contained 518 consecutive HFpEF patients hospitalized for acute decompensated heart failure (HF). The primary outcome was a composite of cardiovascular death and HF readmission. We compared the incidence of cardiovascular events between patients who were prescribed with MRAs and those who were not in a propensity score matched cohort using a Cox proportional hazards regression model with a propensity score derived from 23 baseline variables. For sensitivity analysis, we conducted Cox proportional hazards regression models for the primary outcome adjusting for 16 clinically relevant variables in the crude cohort. The median age was 83 years, and 53% were female. The median left ventricular ejection fraction was 61%. During a median follow-up of 553 days, the primary outcome occurred in 192 (37%) patients. MRAs were used in 255 (49%) patients. After analysis, a matched cohort consisting of 370 patients was created. After propensity score matching, the baseline characteristics were well balanced between the two groups. The incidence of the primary outcome was significantly lower in MRA users than in non-users [32% (59/185) vs. 49% (90/185); hazard ratio (HR) 0.669, 95% confidence interval (CI) 0.482-0.929, P = 0.016]. The incidence of cardiovascular death was also significantly lower in the MRA users [11% (21/185) vs. 22% (41/185); HR, 0.563; 95% CI, 0.333-0.953; P = 0.032]. The risk of HF readmission tended to be lower in the MRA users [29% (54/185) vs. 41% (75/185); HR, 0.738; 95% CI, 0.520-1.048; P = 0.089]. MRA use was also associated with a lower risk of the primary outcome after Cox proportional hazards analysis adjusting for 16 clinically relevant variables in the crude cohort (HR, 0.710; 95% CI 0.507-0.995; P = 0.047).

CONCLUSIONS

Mineralocorticoid receptor antagonist use was significantly associated with a lower risk of the primary composite outcome of cardiovascular death and HF readmission in patients hospitalized for acute decompensated HFpEF. The incidence of cardiovascular mortality was also significantly lower in these patients.

Hypokalemia is frequent and has prognostic implications in stable patients attending the emergency department

BACKGROUND

Potassium disturbances are associated with adverse prognosis in patients with chronic conditions. Its prognostic implications in stable patients attending the emergency department (ED) is poorly described.

AIMS

This study aimed to assess the prevalence of dyskalemia, describe its predisposing factors and prognostic associations in a population presenting the ED without unstable medical illness.

METHODS

Post-hoc analysis of a prospective, cross-sectional, multicenter study in the ED of 11 French academic hospitals over a period of 8 weeks. All adults presenting to the ED during this period were included, except instances of self-drug poisoning, inability to complete self-medication questionnaire, presence of an unstable medical illness and decline to participate in the study. All-cause hospitalization or deaths were assessed.

RESULTS

A total of 1242 patients were included. The mean age was 57.2±22.3 years, 51% were female. The distribution according to potassium concentrations was: hypokalemia<4mmol/L(n = 620, 49.9%), normokalemia 4-5mmol/L(n = 549, 44.2%) and hyperkalemia >5mmol/L(n = 73, 0,6%). The proportion of patients with a kalemia<3.5mmol/L was 8% (n = 101). Renal insufficiency (OR [95% CI] = 3.56[1.94-6.52], p-value <0.001) and hemoglobin <12g/dl (OR [95% CI] = 2.62[1.50-4.60], p-value = 0.001) were associated with hyperkalemia. Female sex (OR [95% CI] = 1.31[1.03-1.66], p-value = 0.029), age <45years (OR [95% CI] = 1.69 [1.20-2.37], p-value = 0.002) and the use of thiazide diuretics (OR [95% CI] = 2.04 [1.28-3.32], p-value = 0.003), were associated with hypokalemia<4mmol/l. Two patients died in the ED and 629 (52.7%) were hospitalized. Hypokalemia <3.5mmol/L was independently associated with increased odds of hospitalization or death (OR [95% CI] = 1.47 [1.00-2.15], p-value = 0.048).

CONCLUSIONS

Hypokalemia is frequently found in the ED and was associated with worse outcomes in a low-risk ED population.

Torasemide versus furosemide in treatment of heart failure: A systematic review and meta-analysis of randomized controlled trials

AIM

Diuretics are a cornerstone in treatment of heart failure (HF). Torasemide is a loop diuretic with a potential advantage over other diuretics. We aim to meta-analyse and compare the effect of torasemide with furosemide in HF patients.

METHODS

A comprehensive literature search using 12 databases including PubMed, Scopus, and Web of Science was performed. All randomized controlled trials (RCTs) comparing furosemide and torasemide in HF patients were included and meta-analysed. We assessed the risk of bias using Cochrane Collaboration's tool. The protocol was registered in PROSPERO (CRD42016046112).

RESULTS

Eighteen RCTs with 1598 patients were included. There was a significant difference between torasemide 20 mg and furosemide 40 mg in increasing the urine volume (standard difference of the mean (SDM) [95% confidence interval] = -0.78 [-1.52 to -0.053], P = .036). Torasemide 10 mg and 10 to 20 mg have a significant effect on potassium excretion in comparison with furosemide 25 to 40 mg (P = .018 and .023, respectively). In general, torasemide and furosemide have no significant difference in mortality, edema improvement, weight loss, heart rate, and reducing systolic/diastolic blood pressure. However, oral torasemide has a significant lower hospital stay P < .001 and superior effect in improving ejection fraction P = .029.

CONCLUSION

Although not all results are statistically significant, torasemide has potential advantages on multiple aspects of HF management when compared with furosemide. More studies are needed to clarify these effects.

Hyperkalemia in heart failure: Foe or friend?

Hyperkalemia is a frequent and sometimes life‐threatening condition that may be associated with arrhythmia and cardiac dysfunction in patients with heart failure (HF). High potassium levels in HF represent both a direct risk for cardiovascular complication and an indirect biomarker of the severity of the underlying disease, reflecting neurohormonal activation and renal dysfunction. Evaluating the prevalence and significance of hyperkalemia in HF patients is essential for optimizing the use of potassium sparing agents, such the renin–angiotensin–aldosterone system inhibitors (RAASi) or angiotensin receptor‐neprilysin inhibitors and mineralocorticoid receptor antagonists, which represent a well‐established cornerstone and life‐saving therapy. In this review we discuss recent findings and current concepts related to the epidemiology, pathological mechanisms and implications of hyperkalemia, as well as novel therapeutic approaches to counteract it in patients with HF. The balance between optimizing life‐saving potassium sparing medication and minimizing hyperkalemia‐associated risk is much needed in patients with HF. Although older potassium‐binding agents are associated with serious adverse events, novel potassium‐binding drugs are effective in lowering potassium levels and are generally well tolerated. Novel potassium‐binding drugs, such as patiromer and sodium zirconium cyclosilicate, may help to optimize therapy in HF and achieve guideline‐recommended doses. Hyperkalemia is common in HF patients and is associated with a poorer prognosis and an increased risk of cardiovascular complications: Contrariwise, “moderate” potassium levels go with a better prognosis, while the emergence of new drugs, potassium binders, could allow target doses of RAASi to be achieved.

Effect of mineralocorticoid receptor antagonists on cardiac function in patients with heart failure and preserved ejection fraction: a systematic review and meta-analysis of randomized controlled trials

Heart failure with preserved ejection fraction (HFpEF) is a disease with limited evidence-based treatment options. Mineralocorticoid receptor antagonists (MRA) offer benefit in heart failure with reduced ejection fraction (HFrEF), but their impact in HFpEF remains unclear. We therefore evaluated the effect of MRA on echocardiographic, functional, and systemic parameters in patients with HFpEF by a systematic review and meta-analysis. We searched MEDLINE, EMBASE, clinicaltrials.gov, and Cochrane Clinical Trial Collection to identify randomized controlled trials that (a) compared MRA versus placebo/control in patients with HFpEF and (b) reported echocardiographic, functional, and/or systemic parameters relevant to HFpEF. Studies were excluded if: they enrolled asymptomatic patients; patients with HFrEF; patients after an acute coronary event; compared MRA to another active comparator; or reported a follow-up of less than 6 months. Primary outcomes were changes in echocardiographic parameters. Secondary end-points were changes in functional capacity, quality of life measures, and systemic parameters. Quantitative analysis was performed by generating forest plots and calculating effect sizes by random-effect models. Between-study heterogeneity was assessed through Q and I² statistics. Nine trials with 1164 patients were included. MRA significantly decreased E/e′ (mean difference − 1.37, 95% confidence interval − 1.72 to − 1.02), E/A (− 0.04, − 0.08 to 0.00), left ventricular end-diastolic diameter (− 0.78 mm, − 1.34 to − 0.22), left atrial volume index (− 1.12 ml/m², − 1.91 to − 0.33), 6-min walk test distance (− 11.56 m, − 21 to − 2.13), systolic (− 4.75 mmHg, − 8.94 to − 0.56) and diastolic blood pressure (− 2.91 mmHg, − 4.15 to − 1.67), and increased levels of serum potassium (0.23 mmol/L, 0.19 to 0.28) when compared with placebo/control. In patients with HFpEF, MRA treatment significantly improves indices of cardiac structure and function, suggesting a decrease in left ventricular filling pressure and reverse cardiac remodeling. MRA increase serum potassium and decrease blood pressure; however, a small decrease in 6-min-walk distance is also noted. Larger prospective studies are warranted to provide definitive answers on the effect of MRA in patients with HFpEF.

Hypokalaemia and outcomes in older patients hospitalized for heart failure

Aims

Hypokalaemia is a risk factor for ventricular arrhythmias and sudden death in ambulatory patients with chronic heart failure (HF). The objective of this study was to examine the association between hypokalaemia and outcomes in hospitalized patients with decompensated HF in whom sudden death is less common.

Methods and results

Of the 5881 hospitalized patients with HF, 1052 had consistent hypokalaemia (both admission and discharge serum potassium <4.0 mmol/L), and 2538 had consistent normokalaemia (both admission and discharge serum potassium 4.0–5.0 mmol/L). Propensity scores for consistent hypokalaemia, estimated for each of 3590 (1052 + 2538) patients, were used to assemble a matched cohort of 971 pairs of patients with consistent hypokalaemia vs. consistent normokalaemia, balanced on 54 baseline characteristics (mean age, 75 years; 60% women; 28% African American). We repeated the above process to assemble 2327 pairs of patients with discharge potassium <4.0 vs. 4.0–5.0 mmol/L and 449 pairs of patients with discharge serum potassium <3.5 vs. 4.0–5.0 mmol/L. Hazard ratios (HR) and 95% confidence intervals (CIs) associated with hypokalaemia were estimated in matched cohorts. 30 day all‐cause mortality occurred in 5% and 4% of patients with consistent normokalaemia vs. consistent hypokalaemia, respectively (HR, 0.78; 95% CI, 0.52–1.18; P = 0.241). HRs (95% CI) for 30 day mortality associated with discharge serum potassium <4.0 and <3.5 mmol/L were 0.90 (0.70–1.16; P = 0.419) and 1.69 (0.94–3.04; P = 0.078), respectively. Hypokalaemia (<4.0 or <3.5 mmol/L) had no association with long‐term mortality or other outcomes.

Conclusions

In hospitalized older patients with HF, compared with normokalaemia (serum potassium 4.0–5.0 mmol/L), hypokalaemia (<4.0 or <3.5 mmol/L) had no significant associations with outcomes.

Medication as a risk factor for hospitalization due to heart failure and shock: a series of case-crossover studies in Swiss claims data

Purpose

Heart failure is among the leading causes for hospitalization in Europe. In this study, we evaluate potential precipitating factors for hospitalization for heart failure and shock.

Methods

Using Swiss claims data (2014–2015), we evaluated the association between hospitalization for heart failure and shock, and prescription of oral potassium supplements, non-steroidal anti-inflammatory drugs (NSAIDs), and amoxicillin/clavulanic acid. We conducted case-crossover analyses, where exposure was compared for the hazard period and the primary control period (e.g., 1–30 days before hospitalization vs. 31–60 days, respectively). Conditional logistic regression was applied and subsequently adjusted for addressing potential confounding by disease progression. Sensitivity analyses were conducted and stratification for co-medication was performed.

Results

We identified 2185 patients hospitalized with heart failure or shock. Prescription of potassium supplements, NSAIDs, and amoxicillin/clavulanic acid was significantly associated with an increased risk for hospitalization for heart failure and shock with crude odds ratios (OR) of 2.04 for potassium (95% CI 1.24–3.36, p = 0.005, 30 days), OR 1.8 for NSAIDs (95% CI 1.39–2.33, p < 0.0001, 30 days), and OR 3.25 for amoxicillin/clavulanic acid (95% CI 2.06–5.14, p < 0.0001, 15 days), respectively. Adjustment attenuated odds ratios, while the significant positive association remained (potassium OR 1.70 (95% CI 1.01–2.86, p = 0.046), NSAIDs OR 1.50 (95% CI 1.14–1.97, p = 0.003), and amoxicillin/clavulanic acid OR 2.26 (95% CI 1.41–3.62, p = 0.001).

Conclusion

Prescription of potassium supplements, NSAIDs, and amoxicillin/clavulanic acid is associated with increased risk for hospitalization. Underlying conditions such as pain, electrolyte imbalances, and infections are likely contributing risk factors. Physicians may use this knowledge to better identify patients at risk and adapt patient management.

Electronic supplementary material

The online version of this article (10.1007/s00228-020-02835-x) contains supplementary material, which is available to authorized users.

Short-term prognosis of normalising serum potassium following an episode of hypokalaemia in patients with chronic heart failure

BACKGROUND/ AIM

It is well known that patients with chronic heart failure and hypokalaemia have increased mortality risk. We investigated the impact of normalising serum potassium following an episode of hypokalaemia on short-term mortality among patients with chronic heart failure.

METHODS AND RESULTS

We identified 1673 patients diagnosed with chronic heart failure who had a serum potassium measurement under 3.5 mmol/l within 14 days and one year after initiated medical treatment with both loop diuretics and angiotensin-converting enzyme inhibitors or angiotensin-II receptor blockers. A second serum potassium measurement was required 8-30 days after the episode of hypokalaemia. All-cause mortality and cardiovascular mortality was examined within 90 days from the second serum potassium measurement. Mortality was examined according to six predefined potassium groups derived from the second measurement:<3.5 mmol/l (n = 302), 3.5-3.7 mmol/l (n = 271), 3.8-4.1 mmol/l (n = 464), 4.2-4.4 mmol/l (n = 270), 4.5-5.0 mmol/l (n = 272), and 5.1-8.0 mmol/l (n = 94). We used Cox regression to estimate both all-cause mortality risk and cardiovascular mortality, with serum potassium at 3.8-4.1 mmol/l as reference. After 90 days, the all-cause mortality in the six groups was 29.5%, 22.1%, 20.3%, 24.8%, 23.5% and 43.6%, respectively. In multivariable adjusted analysis, patients with serum potassium <3.5 mmol/l (hazard ratio: 1.51; 95% confidence interval: 1.13-2.02) and serum potassium 5.1-8.0 mmol/l (hazard ratio: 2.18; 95% confidence interval: 1.50-3.17) had an increased risk of all-cause mortality compared to the reference. After 90 days, the cardiovascular mortality in the six groups was 19.2%, 17.7%, 14.4%, 18.9%, 18.8% and 34.0%, respectively. In multivariable adjusted analysis, patients with serum potassium 5.1-8.0 mmol/l (hazard ratio: 2.32; 95% confidence interval: 1.51-3.56) had an increased risk of cardiovascular mortality compared to the reference, while serum potassium <3.5 mmol/l (hazard ratio: 1.37; 95% confidence interval: 0.97-1.95) had a trend toward increased risk of cardiovascular mortality compared to the reference.

CONCLUSION

Patients with chronic heart failure and hypokalaemia, who after 8-30 days remained hypokalaemic, had a significantly higher 90-day all-cause mortality risk compared to patients in the reference group (3.8-4.1 mmol/l). Patients with chronic heart failure and hypokalaemia, who after 8-30 days had the serum potassium level increased to a level within 5.1-8.0 mmol/l, had both a significantly higher 90-day all-cause mortality risk and cardiovascular mortality risk compared to patients in the reference group (3.8-4.1 mmol/l).

Suadian Acacia Gerrardii: Antidiabetic Effect in Rats Suffering from Diabetic Nephropathy and DNA Fingerprinting Using ISSR

BACKGROUND AND OBJECTIVE

There is a widespread use of medicinal herbs with beneficial uses against different diseased conditions. This study was carried out to identify and study the biological effect of Acacia gerrardii leaf extract on lowering blood sugar in rats suffering from diabetic nephropathy.

MATERIALS AND METHODS

It studied the effects of leaf extract at concentrations ranging from 100-500 mg kg-1 b.wt. per day for 4 weeks. Serum glucose levels, total lipids profile and kidney functions were estimated. Plasma levels of sodium and potassium as well as total bilirubin levels were assessed and kidneys from different groups were histopathologically examined.

RESULTS

The results showed that leaves were rich in the major compounds of phenolic acids, including salicylic acid and flavonoids with reduction of total lipids, triglycerides and total cholesterol in diabetic rats with renal failure together with reduction in uric acid, creatinine and urea with reduced vacuolar degeneration of tubules and basement membrane thickening. Additionally, the phylogenetic analysis using ISSR primers detected a genetic divergence among different samples. The results showed that the rich antioxidant content of Acacia gerrardii improved lipid, serum antioxidant and kidney function profiles in diabetic rats.

CONCLUSION

Acacia gerrardii could be used as a safe source of antioxidants. Moreover, the ISSR assay proved its usefulness in detecting genetic variations among different Acacia gerrardii samples.

[Incidence and Risk Factors of Hypokalemia in Tazobactam/Piperacillin-administered Patients]

Tazobactam/piperacillin (TAZ/PIPC) is a useful antimicrobial agent with broad antibacterial activity. Hypokalemia is considered a rare side effect of TAZ/PIPC; however, it may occur more often than previously thought. In this study, hypokalemia frequency and risk factors were examined in 420 patients treated with TAZ/PIPC. Our results demonstrated that the hypokalemia incidence was 24.8% (grade 1-2: 18.3%, grade 3-4: 6.4%). In addition, multivariate analysis revealed that age [odds ratio 1.057, 95% confidence interval 1.024-1.090, cutoff value 80.5 years] is a risk factor. Although the "Daily dosage/creatinine clearance" was not significant in multivariate analysis, univariate analysis indicated it be to be significant, with a cutoff value of 294.9 mg/mL/min. Furthermore, a "body mass index of 19.7 kg/m² or higher", "serum potassium level before administration of 3.95 mEq/L or more", and "no empirical treatment for administration purposes" appeared to prevent the hypokalemia development. Overall, the hypokalemia incidence rate in TAZ/PIPC-administered patients was as high as 20%, with patients aged >80.5 years considered a high-risk group. Thus, careful monitoring of potassium levels in patients treated with TAZ/PIPC, particularly those aged >81 years, is warranted.

Dyskalemia, its patterns, and prognosis among patients with incident heart failure: A nationwide study of US veterans

Background

Although hypokalemia has been viewed as a significant concern among patients with heart failure (HF), recent advances in HF management tend to increase the risk of hyperkalemia.

Objective

To characterize contemporary data regarding correlates and prognostic values of dyskalemia in patients with HF.

Design, setting, and participants

In cross-sectional and longitudinal analyses, we studied 142,087 patients with newly diagnosed HF in US nationwide Veterans Administration database from 2005 through 2013.

Exposures

Demographic characteristics, laboratory variables, comorbidities, and medication use for the analysis of correlates of dyskalemia as well as potassium level in the analysis of mortality.

Main Outcomes and Measures

Dyskalemia and mortality.

Results

Hypokalemia (<3.5 mmol/L) at baseline was observed in 3.0% of the population, whereas hyperkalemia (≥5.5 mmol/L) was seen in 0.9%. An additional 20.4% and 5.7% had mild hypokalemia (3.5–3.9 mmol/L) and mild hyperkalemia (5.0–5.4 mmol/L). Key correlates were black race, higher blood pressure, and use of potassium-wasting diuretics for hypokalemia, and lower kidney function for hyperkalemia. Baseline potassium levels showed a U-shaped association with mortality, with the lowest risk between 4.0–4.5 mmol/L. With respect to potassium levels over a year after HF diagnosis, persistent (>50% of measurements), intermittent (>1 occurrence but ≤50%), and transient (1 occurrence) hypo- and hyperkalemia were also related to increased mortality in a graded fashion regardless of the aforementioned thresholds for dyskalemia. These dyskalemic patterns were also related to other clinical actions and demands such as emergency room visit.

Conclusions

Potassium levels below 4 mmol/L and above 5 mmol/L at and after HF diagnosis were associated with poor prognosis and the clinical actions. HF patients (particularly with risk factors for dyskalemia like black race and kidney dysfunction) may require special attention for both hypo- and hyperkalemia.

Influence of abnormal potassium levels on mortality among hospitalized heart failure patients in the US: data from National Inpatient Sample

Background: Abnormalities in serum potassium levels have been associated with variable mortality risk among hospitalized patients with heart failure (HF). We aim to use a large database study to further characterize risk of mortality, demographic factors, and associated comorbidities among heart failure inpatients.

Methods: Our sample population was from the US National Inpatient Sample database from the year 2009–2011. The inclusion criteria used to identify patients was those with a diagnosis of heart failure as per ICD-9 classification. Other demographic factors considered in data collection included income, and cardiac risk factors. Taking these factors into consideration, a univariate association of potassium level and mortality was performed, as well as multivariable logistic regression controlling for demographic factors and associated conditions.

Results: Of the 2,660,609 patients who were discharged with a diagnosis of heart failure during this time period, patients with hypokalemia during hospitalization had increased mortality risk (OR: 1.96, 95% CI: 1.91–2.01) when compared with those with hyperkalemia who had decreased inpatient mortality risk OR: 0.94,95% CI: 0.91–0.96) versus those not coded for potassium abnormalities. This finding was significant even regardless of the etiology of the hypokalemia while the hyperkalemic patients were noted to have no difference or a decreased risk in all subtypes and groups.

Conclusion: Unlike heart failure patients with hyperkalemia, those with hypokalemia are at an increased inpatient mortality risk. Whether our mortality findings translate to longer-term outpatient settings where significantly less monitoring is possible is a matter for further study.

Nutritional Considerations of Cardiovascular Diseases and Treatments

Nutritional considerations of many chronic diseases are not fully understood or taken into consideration in everyday clinical practice. Therefore, it is not surprising that high proportion of hospitalized patients with cardiovascular diseases remains underdiagnosed with malnutrition. Malnourished patients have increased risk of poor clinical outcomes, complications rate, prolonged hospital stay, more frequent rehospitalizations, and lower quality of life. The purpose of this review is to recapitulate recent data on nutritional considerations in cardiovascular medicine.

Management of hyperkalemia in the acutely ill patient

Purpose

To review the mechanisms of action, expected efficacy and side effects of strategies to control hyperkalemia in acutely ill patients.

Methods

We searched MEDLINE and EMBASE for relevant papers published in English between Jan 1, 1938, and July 1, 2018, in accordance with the PRISMA Statement using the following terms: “hyperkalemia,” “intensive care,” “acute kidney injury,” “acute kidney failure,” “hyperkalemia treatment,” “renal replacement therapy,” “dialysis,” “sodium bicarbonate,” “emergency,” “acute.” Reports from within the past 10 years were selected preferentially, together with highly relevant older publications.

Results

Hyperkalemia is a potentially life-threatening electrolyte abnormality and may cause cardiac electrophysiological disturbances in the acutely ill patient. Frequently used therapies for hyperkalemia may, however, also be associated with morbidity. Therapeutics may include the simultaneous administration of insulin and glucose (associated with frequent dysglycemic complications), β-2 agonists (associated with potential cardiac ischemia and arrhythmias), hypertonic sodium bicarbonate infusion in the acidotic patient (representing a large hypertonic sodium load) and renal replacement therapy (effective but invasive). Potassium-lowering drugs can cause rapid decrease in serum potassium level leading to cardiac hyperexcitability and rhythm disorders.

Conclusions

Treatment of hyperkalemia should not only focus on the ability of specific therapies to lower serum potassium level but also on their potential side effects. Tailoring treatment to the patient condition and situation may limit the risks.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0509-8) contains supplementary material, which is available to authorized users.