Optimizing Therapies in Heart Failure: The Role of Potassium Binders

Abstract

Heart failure (HF) is a worrisome cardiac pandemic with a negative prognostic impact on the overall survival of individuals. International guidelines recommend up-titration of standardized therapies in order to reduce symptoms, hospitalization rates, and cardiac death. Hyperkalemia (HK) has been identified in 3–18% of HF patients from randomized controlled trials and over 25% of HF patients in the “real world” setting. Pharmacological treatments and/or cardio-renal syndrome, as well as chronic kidney disease may be responsible for HK in HF patients. These conditions can prevent the upgrade of pharmacological treatments, thus, negatively impacting on the overall prognosis of patients. Potassium binders may be the best option in patients with HK in order to reduce serum concentrations of K+ and to promote correct upgrades of therapies. In addition to the well-established use of sodium polystyrene sulfonate (SPS), two novel drugs have been recently introduced: sodium zirconium cyclosilicate (SZC) and patiromer. SZC and patiromer are gaining a central role for the treatment of chronic HK. SZC has been shown to reduce K+ levels within 48 h, with guaranteed maintenance of normokalemia for up to12 months. Patiromer has resulted in a statistically significant decrease in serum potassium for up to 52 weeks. Therefore, long-term results seemed to positively promote the implementation of these compounds in clinical practice due to their low rate side effects. The aim of this narrative review is to delineate the impact of new potassium binders in the treatment of patients with HF by providing a critical reappraisal for daily application of novel therapies for hyperkalemia in the HF setting.

The efficacy and safety of new potassium binders on renin–angiotensin–aldosterone system inhibitor optimization in heart failure patients: a systematic review and meta‐analysis

“…28 can be managed by adding NPB to aid in continuing and reaching RAASi target doses as higher plasma potassium levels are also associated with increased risks of all-cause mortality, cardiovascular death, HF-related death, and sudden cardiac death, even when considering other influencing factors. 29 In our meta-analysis, NPBs significantly reduced suboptimal MRA doses and optimized MRA dosage. However, no effect was observed on ACEi/ARB/ANRi optimization.…”

“…Scicchitano et al . reported a notable 75% mortality rate in HFrEF patients who stopped MRA over 65 months 29 . This challenging effect can be managed by adding NPB to aid in continuing and reaching RAASi target doses as higher plasma potassium levels are also associated with increased risks of all‐cause mortality, cardiovascular death, HF‐related death, and sudden cardiac death, even when considering other influencing factors 29 …”

“…Scicchitano et al reported a notable 75% mortality rate in HFrEF patients who stopped MRA over 65 months 29. This challenging effect Baseline characteristics of the participants…”

Annual evolution of the prescription of drugs with prognostic implications in acute decompensated heart failure with reduced ejection fraction

“…It would be of interest to analyze the impact of the different reasons why, in a certain percentage of patients, the 4 pharmacological groups are not implemented. Most likely, among these factors is hyperkalemia, that can impact the management of patients with HF by promoting the discontinuation of therapies, thus, negatively increasing the risk for mortality [ 30 ].…”