Rethinking Hyperkalemia Care in Patients With Heart Failure

By Ravi Dhingra, MD, MPH, FACC, FAHA
Sponsored By AstraZeneca

Renin-angiotensin-aldosterone system inhibitor (RAASi) therapy is a cornerstone of heart failure (HF) management, yet concerns about hyperkalemia (HK) can limit its use.¹ In chronic HF management, a long-term approach to addressing HK is an important consideration for healthcare providers.

An observational study² utilizing Optum’s de-identified Market Clarity Data from July 2019 to September 2021, evaluated the risk of HF-related hospitalizations or HF ED visits and progression to end-stage kidney disease (ESKD) in 15,488 adult patients from the US with HF and/or chronic kidney disease (CKD) stage 3 or 4. Patients who experienced an index HK event (based on International Classification of Diseases codes) and had ≥1 filled RAASi prescription within 6 months before the index HK event were assessed. All RAASi classes were included.

• 33% of patients discontinued RAASi (no fill of a new prescription within 90 days), and 7% down-titrated (>25% reduction in dose) at least one RAASi following HK.²
• Risk of HF-related hospitalizations or HF ED visits and progression to ESKD increased with RAASi discontinuation (adjusted hazard ratio [HR] 1.55; 95% confidence interval [CI] 1.38-1.75) and RAASi down-titration (adjusted HR 1.51; 95% CI 1.24-1.86) compared to patients who maintained or up-titrated RAASi at 6 months.²
• Key limitation: A higher proportion of patients who discontinued or down-titrated RAASi therapy had severe index HK episode (potassium [K⁺] ≥6.0 mEq/L) and higher use of mineralocorticoid receptor antagonist at baseline compared to patients who maintained or up-titrated RAASi.²

These data highlight the need to treat HK to allow for continuation of RAASi therapy in patients with HF. 

For many patients with HF and other co-morbid cardiovascular conditions like hypertension, HK is not a single event but a recurring challenge.³ Recognizing this challenge is important when considering treatment decisions. 

Providers can consider treating and maintaining HK long-term with the continuous use of a K⁺ binder.⁴ Treating HK helps to support continuation of guideline-recommended RAASi therapy.¹

• The 2022 American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Failure Society of America (HFSA) Guideline for the Management of HF highlights that K⁺ binders have been shown to lower K⁺ levels. Managing HK may enable treatment with RAASi in patients with HF.¹

The Takeaway

HK can be a barrier to optimization of guideline-recommended RAASi therapy. K⁺ binders have been shown to lower potassium levels. Managing HK may enable RAASi treatment in patients with HF. Learn more about a novel K⁺ binder for the treatment of HK here. 

References

1. Heidenreich Paul A, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022;79(17):e263-e421.
2. Kanda E, et al. Clinical impact of suboptimal RAASi therapy following an episode of hyperkalemia. BMC Nephrol. 2023;24(1):18
3. Rowan CG, et al. Hyperkalemia recurrence following medical nutrition therapy in patients with Stage 3-4 chronic kidney disease: The REVOLUTIONIZE I Real-World Study. Adv Ther. 2024;41(6):2381-2398.
4. Kosiborod M, Rasmussen HS, Lavin P, et al. Effect of sodium zirconium cyclosilicate on potassium lowering for 28 days among outpatients with hyperkalemia: the HARMONIZE randomized clinical trial. JAMA. 2014;312(21):2223-2233.