Hyperkalemia Associated with Renin-Angiotensin-Aldosterone System Inhibition in Patients with Heart Failure; Underexplored and Overrated?

Real or Perceived: Hyperkalemia Is a Major Deterrent for Renin-Angiotensin Aldosterone System Inhibition in Heart Failure

“…Both the common soil and the clinical outcomes of chronic kidney disease (CKD) and HF are strong mandates for angiotensin converting enzyme inhibitors (ACEI), angiotensin II receptor antagonists (ARB), and mineralocorticoid receptor antagonists (MRA) in the setting of HF, collectively termed renin-angiotensin aldosterone system (RAAS) inhibition. In this issue of Nephron, Koratala et al [4] contend that “…RAAS inhibitor discontinuation rate due to hyperkalemia was reported to be as low as 0.1–3.4%, and there was no strong association reported between hyperkalemia and worse outcomes.” We believe this conclusion is based on a rather narrow view of the clinical literature on this topic.…”

“…Thus, it has been difficult to implicate the drug. A total of 5 out of the 6 randomized trials listed by Koratala et al [4] that provided data on baseline renal function had creatinine values ranging between 1.0 and 1.2 mg/dL, and the 6th excluded patients with advanced CKD. This is not representative of the patient phenotype that is at risk for hyperkalemia in patients with cardio-renal decompensation being treated with RAAS inhibition.…”