Hyperkalemia is independently associated with unsuccessful ACE-I/ARBs uptitration in heart failure patients with reduced ejection fraction

Beusekamp, J.C. (Joost) (2016) Hyperkalemia is independently associated with unsuccessful ACE-I/ARBs uptitration in heart failure patients with reduced ejection fraction. thesis, Medicine.

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Abstract

Introduction: Multiple trials have demonstrated the positive effects of a guideline-recommended dose of beta-blockers and angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARBs) on the overall outcome of chronic heart failure (HF) patients. In general practice however, lower doses are prescribed due to the fear of side-effects, including hyperkalemia. It is unknown if this fear is well-founded and hyperkalemia is independently associated with suboptimal treatment and poor outcome in the general HF population. Therefore, we examined if serum potassium levels are an independent predictor for successful ACE-I/ARBs uptitration and better outcome. Methods: In this study 1,866 chronic HF patients with reduced left ventricular ejection fraction (LVEF), originating from the international multicenter BIOSTAT-CHF study, were included. Patients were divided into respectively hypokalemia (K<3.5 mmol/L), normokalemia, and hyperkalemia (K>5.0 mmol/L). We studied baseline characteristics, clinical correlations with serum potassium levels and successful uptitration of ACE-I/ARBs or beta-blockers, and examined survival analysis. Uptitration of ACE-I/ARBs or beta-blockers was considered successful if patients obtained over 50% of the target dose after nine months and the administered dose at nine months was higher than the dose administered at baseline. Study endpoints were to test the relation between serum potassium levels and uptitration success of ACE-I/ARBs and its effect on long-term outcome (all-cause mortality + HF rehospitalization). Results: In patients, mean age (± standard deviation) was 68 (± 12) years, median LVEF was 30 (interquartile range 25-30), mean eGFR was 65 (± 24) mL/min/1.73m2, mean serum potassium was 4.3 (± 0.6) mmol/L, median BNP levels were 237 (interquartile range 92–489) ng/L, and 13% received the target dose of ACE-I/ARBs. In total 152 patients (8.1%) were classified as hyperkalemic and high potassium levels were associated with a lower eGFR, mineralocorticoid receptor antagonists (MRAs) therapy, higher serum levels of platelets, and lower BNP levels (all p<0.05). In total, 283 patients (15.2%) were successfully uptitrated with ACE-I/ARBs. In a multivariable analysis higher serum potassium levels, a higher age, a lower eGFR, a lower blood pressure, and MRA-treatment were independent predictors for less successful uptitration. This potassium related difference in uptitration was not found in the beta-blocker group. Conclusion: Hyperkalemia is independently associated with unsuccessful uptitration of ACE-I/ARBs in HF patients. Safely lowering potassium levels might be advisable to improve the tolerated target dose fraction and by that, improve the long-term prognosis.

Item Type:	Thesis (Thesis)
Supervisor name:	Meer Peter van der MD PhD and Wal, Haye H. van der and Department of Cardiology, University Medical Center Groninge
Faculty:	Medical Sciences
Date Deposited:	25 Jun 2020 10:46
Last Modified:	25 Jun 2020 10:46
URI:	https://umcg.studenttheses.ub.rug.nl/id/eprint/775

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