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. 2020 Aug;22(8):1378-1389.
doi: 10.1002/ejhf.1793. Epub 2020 Apr 3.

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

Patrick Rossignol  1 , Mitja Lainscak  2 , Maria G Crespo-Leiro  3 , Cécile Laroche  4 , Massimo F Piepoli  5 , Gerasimos Filippatos  6 , Giuseppe M C Rosano  7 , Gianluigi Savarese  8 , Stefan D Anker  9 , Petar M Seferovic  10 , Frank Ruschitzka  11 , Andrew J S Coats  7 , Alexandre Mebazaa  12 , Theresa McDonagh  13 , Ana Sahuquillo  14 , Maria Penco  15 , Aldo P Maggioni  4   16 , Lars H Lund  17 ; Heart Failure Long-Term Registry Investigators Group
Collaborators, Affiliations
Free article

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

Patrick Rossignol et al. Eur J Heart Fail. 2020 Aug.
Free article

Abstract

Aims: We assessed the interplay between hyperkalaemia (HK) and renin-angiotensin-aldosterone system inhibitor (RAASi) use, dose and discontinuation, and their association with all-cause or cardiovascular death in patients with chronic heart failure (HF). We hypothesized that HK-associated increased death may be related to RAASi withdrawal.

Methods and results: The ESC-HFA-EORP Heart Failure Long-Term Registry was used. Among 9222 outpatients (HF with reduced ejection fraction: 60.6%, HF with mid-range ejection fraction: 22.9%, HF with preserved ejection fraction: 16.5%) from 31 countries, 16.6% had HK (≥5.0 mmol/L) at baseline. Angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) was used in 88.3%, a mineralocorticoid receptor antagonist (MRA) in 58.7%, or a combination in 53.2%; of these, at ≥50% of target dose in ACEi: 61.8%; ARB: 64.7%; and MRA: 90.3%. At a median follow-up of 12.2 months, there were 789 deaths (8.6%). Both hypokalaemia and HK were independently associated with higher mortality, and ACEi/ARB prescription at baseline with lower mortality. MRA prescription was not retained in the model. In multivariable analyses, HK at baseline was independently associated with MRA non-prescription at baseline and subsequent discontinuation. When considering subsequent discontinuation of RAASi (instead of baseline use), HK was no longer found associated with all-cause deaths. Importantly, all RAASi (ACEi, ARB, or MRA) discontinuations were strongly associated with mortality.

Conclusions: In HF, hyper- and hypokalaemia were associated with mortality. However, when adjusting for RAASi discontinuation, HK was no longer associated with mortality, suggesting that HK may be a risk marker for RAASi discontinuation rather than a risk factor for worse outcomes.

Keywords: Heart failure; Hyperkalaemia; Hypokalaemia; Mineralocorticoid receptor antagonists; Prognosis; Renin-angiotensin-aldosterone system inhibitors.

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