Potassium and the use of renin–angiotensin–aldosterone system inhibitors in heart failure with reduced ejection fraction: data from BIOSTAT-CHF

Joost C. Beusekamp, Jasper Tromp, Haye H. van der Wal, Stefan D. Anker, John G. Cleland, Kenneth Dickstein, Gerasimos Filippatos, Pim van der Harst, Hans L. Hillege, Chim C. Lang, Marco Metra, Leong L. Ng, Piotr Ponikowski, Nilesh J. Samani, Dirk J. van Veldhuisen, Aeilko H. Zwinderman, Patrick Rossignol, Faiez Zannad, Adriaan A. Voors, Peter van der Meer (Lead / Corresponding author)

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Background: Hyperkalemia is a common comorbidity in patients with heart failure with reduced ejection fraction (HFrEF). Whether it affects the use of RAAS-inhibitors and thereby negatively impacts outcome is unknown. Therefore, we investigated the association between potassium and uptitration of ACE-inhibitor/ARB and its association with outcome.
Methods and results: Out of 2,516 patients from the BIOSTAT-CHF study, potassium levels were available in 1,666 patients with HFrEF. These patients were sub-optimally treated with ACEi/ARB or beta-blockers and were anticipated and encouraged to be uptitrated. Potassium levels were available at inclusion and 9 months. Outcome was a composite of all-cause mortality and HF-hospitalization at 2 years.Patients were 67±12 years old and 77% was male. At baseline, median serum potassium was 4.2(3.9–4.6) mEq/L. After 9 months, 401 (24.1%) patients were successfully uptitrated for ACEi/ARB. During this period, mean serum potassium increased by 0.16±0.66 mEq/L (p<0.001). Baseline potassium was an independent predictor for lower obtained dosages of ACEi/ARB (OR 0.70; 95%CI 0.51–0.98). An increase in potassium was not associated with adverse outcomes (HR 1.15; 95%CI 0.86–1.53). No interaction was found between baseline potassium, potassium increase during uptitration or potassium at 9 months and an increase of dose of ACEi/ARB for outcome (pinteraction for all >0.5).
Conclusion: Higher potassium levels are an independent predictor of enduring lower dosages of ACEi/ARB. Higher potassium levels do not attenuate the beneficial effects of uptitration ACEi/ARB.
Original languageEnglish
Pages (from-to)923-930
Number of pages8
JournalEuropean Journal of Heart Failure
Issue number5
Early online date12 Jan 2018
Publication statusPublished - 4 May 2018


  • Guideline-directed medication
  • Heart failure
  • Hyperkalaemia
  • Outcome
  • Renin–angiotensin–aldosterone system inhibitors

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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