What is the risk of hyperkalaemia in heart failure?

Hyperkalemia Among Hospitalized Patients and Association Between Duration of Hyperkalemia and Outcomes

Background Hyperkalemia is a serious life-threatening condition that leads to significant morbidity and mortality. Objectives The aim of this study is to investigate the association between the duration and outcomes in patients hospitalized with hyperkalemia, as well as associated risk factors and drug-induced hyperkalemia. Methods A three-year retrospective chart review study was conducted at a tertiary hospital at King Abdulaziz Medical City, Riyadh, Saudi Arabia, between January 2016 and April 2019. We included all hospitalized adults and patients with hyperkalemia. Pediatric patients and dialysis patients with end-stage renal failure were excluded. Results Out of a total of 300 hospitalized patients who were screened for hyperkalemia, only 142 patients were included. The majority of cases were males (56.3%), whereas 43.7% were females. Most patients were above 55 years old. Regarding comorbidities in patients with hyperkalemia, most of them suffered from high blood pressure or diabetes. The mean serum potassium value was 5.7 ± 0.51 mEq. The most frequent medications used in the study population were azole antifungal medication followed by nonsteroidal anti-inflammatory drugs, beta-blockers, and angiotensin-converting enzyme inhibitors. Around 54 patients were not treated with medication and were monitored for spontaneous correction of hyperkalemia. Insulin was the most used medication for the treatment of hyperkalemia. The mean duration for the resolution of hyperkalemia was 12 ±9.4 hours. Out of 142 patients, only 10 (7%) patients died with hyperkalemia. Conclusions Hospitalized patients are at risk of hyperkalemia. In our study, we found that patients who had hyperkalemia were significantly likely to have acute kidney injury or cardiovascular diseases, and azole antifungals and beta-blockers were the most commonly used medications.

Short-term mortality risk of serum potassium levels in acute heart failure following myocardial infarction

AIMS

Diuretic treatment is often needed in acute heart failure following myocardial infarction (MI) and carries a risk of abnormal potassium levels. We examined the relation between different levels of potassium and mortality.

METHODS AND RESULTS

From Danish national registries we identified 2596 patients treated with loop diuretics after their first MI episode where potassium measurement was available within 3 months. All-cause mortality was examined according to seven predefined potassium levels: hypokalaemia <3.5 mmol/L, low normal potassium 3.5-3.8 mmol/L, normal potassium 3.9-4.2 mmol/L, normal potassium 4.3-4.5 mmol/L, high normal potassium 4.6-5.0 mmol/L, mild hyperkalaemia 5.1-5.5 mmol/L, and severe hyperkalaemia: >5.5 mmol/L. Follow-up was 90 days and using normal potassium 3.9-4.2 mmol/L as a reference, we estimated the risk of death with a multivariable-adjusted Cox proportional hazard model. After 90 days, the mortality rates in the seven potassium intervals were 15.7, 13.6, 7.3, 8.1, 10.6, 15.5, and 38.3%, respectively. Multivariable-adjusted risk for death was statistically significant for patients with hypokalaemia [hazard ratio (HR): 1.91, confidence interval (95%CI): 1.14-3.19], and mild and severe hyperkalaemia (HR: 2, CI: 1.25-3.18 and HR: 5.6, CI: 3.38-9.29, respectively). Low and high normal potassium were also associated with increased mortality (HR: 1.84, CI: 1.23-2.76 and HR: 1.55, CI: 1.09-2.22, respectively).

CONCLUSION

Potassium levels outside the interval 3.9-4.5 mmol/L were associated with a substantial risk of death in patients requiring diuretic treatment after an MI.

Risk of hyperkalemia and combined use of spironolactone and long-term ACE inhibitor/angiotensin receptor blocker therapy in heart failure using real-life data: a population- and insurance-based cohort

PURPOSE

Clinical trials and few observational studies report increased hyperkalemia risks in heart failure patients receiving aldosterone blockers in addition to standard therapy. The aim of this study is to assess the hyperkalemia risk and combined use of spironolactone and long-term ACE (angiotensin-converting enzyme) inhibitor/angiotensin receptor blocker (ARB) therapy for heart failure in a real-life setting of a heterogeneous population.

METHODS

Using claims data of the statutory health insurance fund AOK, covering 30% of the German population, we performed a nested case-control study in a cohort of heart failure patients receiving continuous ACE/ARB therapy (n = 1,491,894). Hyperkalemia risk associated with concurrent use of spironolactone and ACE/ARB was calculated by conditional logistic regression in 1062 cases and 10,620 risk-set-sampling-matched controls.

RESULTS

Risk of hyperkalemia in heart failure patients was significantly associated with spironolactone use (odds ratio (OR) (95% confidence interval (CI)) = 13.59 (11.63-15.88) in all and 11.05 (8.67-14.08) in those with information on New York Heart Association (NYHA) stage of disease). In the NYHA subpopulation, higher risk estimates were observed in short-term as compared with long-term users (OR (95%CI) = 13.00 (9.82-17.21) and 9.12 (6.78-12.26), respectively). Moreover, the association was stronger in older (≥70 years of age) as compared with younger patients (<70 years of age) (OR (95%CI) = 12.32 (9.35-16.23) and 8.73 (5.05-15.08), respectively), although interaction was not significant (pinteraction  = 0.07).

CONCLUSIONS

Hyperkalemia risk associated with combined use of spironolactone and ACE/ARB is much stronger in real-life practice than observed in clinical trials. Careful potassium level monitoring in concomitant users of spironolactone and ACE/ARB is necessary.

Medication management of chronic heart failure in older adults

Heart failure (HF) is a common problem in older adults. Individuals aged 65 years or older are at a higher risk for developing HF, especially diastolic HF or HF with preserved ejection fraction (HFpEF). HF can be seen in up to 20 % of adults aged 85 years or older. In contrast to middle-aged (40-64 years) HF patients, multiple cardiac, non-cardiac and geriatric syndrome co-morbidities are seen in elderly HF patients. Additionally, age-related changes in pharmacokinetics and pharmacodynamics influence medication therapy. Hence, the management of older patients with HF is challenging and treatment should be modified in the light of the above-mentioned conditions. This article discusses the current evidence for medication management in both systolic HF or HF with reduced ejection fraction (HFrEF) and HFpEF, noting, however, the limited data for HFpEF and HFrEF in those 80 years of age or older. The objective of this article is to discuss evidence-based and outcomes-driven pharmacologic management strategies for chronic HF in the older adults for whom functional and other patient-centered outcomes might be more than or as important as clinical outcomes. Optimal management would be expected to help to reduce illness burden, reduce mortality and hospitalizations, and improve function and quality of life.

Hyperkalemia among hospitalized patients and association between duration of hyperkalemia and outcomes

INTRODUCTION

The aim of the study was to investigate predictors of mortality in patients hospitalized with hyperkalemia.

MATERIAL AND METHODS

Data among hospitalized patients with hyperkalemia (serum potassium ≥ 5.1 mEq/l) were collected. Patients with end-stage renal disease on dialysis were excluded.

RESULTS

Of 15,608 hospitalizations, 451 (2.9%) episodes of hyperkalemia occurred in 408 patients. In patients with hyperkalemia, chronic kidney disease, hypertension, diabetes, coronary artery disease and heart failure were common comorbidities. Acute kidney injury (AKI) and metabolic acidosis were common metabolic abnormalities, and 359 patients (88%) were on at least one drug associated with hyperkalemia. Mean duration to resolution of hyperkalemia was 12 ±9.9 h. Nonsteroidal anti-inflammatory drugs (HR = 1.59), highest potassium level (HR = 0.61), tissue necrosis (HR = 0.61), metabolic acidosis (HR = 0.77), and AKI (HR = 0.77) were significant independent determinants of duration prior to hyperkalemia resolution. Tissue necrosis (OR = 4.55), potassium supplementation (OR = 5.46), metabolic acidosis (OR = 4.84), use of calcium gluconate for treatment of hyperkalemia (OR = 4.62), AKI (OR = 3.89), and prolonged duration of hyperkalemia (OR = 1.06) were significant independent predictors of in-hospital mortality.

CONCLUSIONS

Tissue necrosis, potassium supplementation, metabolic acidosis, calcium gluconate for treatment of hyperkalemia, AKI and prolonged duration of hyperkalemia are independent predictors of in-hospital mortality.

Interactions of Enhanced Urocortin 2 and Mineralocorticoid Receptor Antagonism in Experimental Heart Failure

Background—

Mineralocorticoid receptor antagonists (MRAs) have become established therapy in heart failure (HF). Urocortin 2 (Ucn2) is a novel peptide with potential in the treatment of this disease. The present study investigated the interactions of acute administration of Ucn2 and an MRA in experimental HF.

Methods and Results—

Ucn2 and an MRA (canrenoic acid [CA]) were infused for 4 hours, both singly and together, in 8 sheeps with pacing-induced HF. Ucn2, when administered as an adjunct to CA, further improved hemodynamic indices relative to that achieved by CA alone, producing additional increases in cardiac output and decreases in left atrial pressure and peripheral resistance but without eliciting a supplementary reduction in arterial pressure. Ucn2 cotreatment reversed CA-induced rises in circulating aldosterone levels, and also significantly reduced plasma renin activity, angiotensin II, and vasopressin concentrations. Although both CA and Ucn2 infusion produced a diuresis and natriuresis, responses with Ucn2 and Ucn+CA were 2- to 3-fold greater than that elicited by separate CA. Ucn2 cotherapy additionally increased urine potassium and creatinine excretion. In contrast to the rise in plasma potassium induced by CA, Ucn2 cotreatment reduced potassium concentrations.

Conclusions—

Ucn2 cotreatment with an MRA in HF further improved hemodynamics relative to that achieved by CA alone, while also reducing plasma renin activity, angiotensin II, aldosterone and vasopressin levels, and enhancing renal function. Importantly, Ucn2 prevented CA-induced rises in plasma potassium. These data demonstrate a favorable profile of effects with short-term adjunct Ucn2 therapy and an MRA in HF.

Lipids, blood pressure, kidney - what was new in 2011?

The year 2011 was very interesting regarding new studies, trials and guidelines in the field of lipidology, hypertensiology and nephrology. Suffice it to mention the new European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines on the management of dyslipidaemias, American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines on hypertension in the elderly, and many important trials presented among others during the American Society of Nephrology (ASN) Annual Congress in Philadelphia and the AHA Annual Congress in Orlando. The paper is an attempt to summarize the most important events and reports in the mentioned areas in the passing year.