Managing Hyperkalemia in Heart Failure Patients: A Systematic Review

Abstract

Hyperkalemia is a common and potentially life-threatening electrolyte abnormality in patients with heart failure, particularly among those with diabetes or chronic kidney disease. It often results from the use of renin-angiotensin-aldosterone system inhibitors, which, while improving survival, increase serum potassium levels. Elevated potassium produces cardiotoxic effects, often recognized by characteristic electrocardiographic changes. Acute management focuses on stabilizing cardiac membranes with intravenous calcium and shifting potassium intracellularly through insulin-dextrose, β₂-agonists, or sodium bicarbonate, with caution to avoid fluid overload. Potassium elimination may be achieved using diuretics or hemodialysis when refractory. For chronic management, newer potassium-binding agents such as patiromer and sodium zirconium cyclosilicate offer improved safety and efficacy compared with traditional resins, enabling the continuation and up-titration of renin-angiotensin-aldosterone system inhibitors. These therapies support optimal neurohormonal blockade, improve adherence, and reduce morbidity and mortality in heart failure.

Keywords: RAAS inhibitors; heart failure; hyperkalemia; patiromer; sodium zirconium cyclosilicate (SZC).