Management of Patients with Heart Failure at High Risk of Hyperkalaemia: The CARE-HK in HF Registry
Year: 2025
Type: article
Study design: Observational Study
Abstract: ABSTRACT Aims Patients with heart failure (HF) at high risk for hyperkalaemia are underrepresented in prospective HF registries. The CARE-HK in HF registry sought to characterize prospectively the clinical profile, management, and outcomes for patients with HF at high risk of hyperkalaemia. Methods and results CARE-HK in HF was a multinational prospective registry of outpatients with HF (regardless of left ventricular ejection fraction [LVEF]) treated with an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker/angiotensin receptor–neprilysin inhibitor (ACEI/ARB/ARNI) and either receiving or potential candidate for a mineralocorticoid receptor antagonist (MRA). All patients were at increased risk of hyperkalaemia, defined as hyperkalaemia at baseline, prior hyperkalaemia, or estimated glomerular filtration rate (eGFR) <45 ml/min/1.73 m2. Outcomes included frequency of hyperkalaemic events (defined by clinician report with associated potassium value), achievement of renin–angiotensin system inhibitor (RASi) optimization (defined as ≥50% target doses for ACEI/ARB/ARNI and MRA), medication changes following hyperkalaemic episodes, and clinical events. Overall, 2558 patients from 111 sites across nine countries were included. Median (25th–75th) age was 73 (65–80) years, 32% were women, 61% had LVEF ≤40%, and 40% had prior laboratory evidence of hyperkalaemia. Median baseline eGFR and serum potassium were 44 (33–60) ml/min/1.73 m2 and 5.0 (4.4–5.3) mEq/L, respectively. Over a median follow-up of 12.3 (9.4–18.1) months, 29% of patients had a hyperkalaemic event, and 7% had multiple events. In characterizing treatment prescribed for most of follow-up, 29% of patients received optimal RASi/MRA therapy, 69% received suboptimal RASi/MRA therapy, and 3% received no RASi/MRA. In the 30 days following the first hyperkalaemic event, RASi/MRA was down-titrated or discontinued in 3.6% of cases. Potassium binder use was low (patiromer 9.1%, sodium zirconium cyclosilicate 5.9%). Compared with patients without a hyperkalaemic event, patients experiencing a hyperkalaemic event had similar risk of all-cause mortality (hazard ratio [HR] 1.22, 95% confidence interval [CI] 0.92–1.62, p = 0.16) and a higher risk of subsequent hospitalization (HR 1.59, 95% CI 1.35–1.86, p < 0.001). Conclusions In this contemporary multinational prospective registry of patients with HF at high risk for hyperkalaemia, hyperkalaemic events were common but infrequently associated with RASi/MRA modification or potassium binder use. Fewer than one in three patients received optimal RASi/MRA therapy for the majority of follow-up, and hyperkalaemic events were associated with higher risk of adverse clinical outcomes. Clinical Trial Registration: ClinicalTrials.gov NCT04864795.
DOI: 10.1002/ejhf.3800
Authors: Stephen J. Greene, Andrew J. Sauer, Michael Böhm, Biykem Bozkurt, Javed Butler, John G.F. Cleland, Andrew J.S. Coats, Nihar R. Desai, Diederick E. Grobbee, Ellie Kelepouris, Fausto Pinto, Giuseppe Rosano, Victoria Donachie, Solenn Fabien, Sandra Waechter, Maria G. Crespo-Leiro, Martin Hülsmann, Tibor Kempf, Otmar Pfister, Anne-Catherine Pouleur, Manish Saxena, Martin Schulz, Maurizio Volterrani, Stefan D. Anker, Mikhail N. Kosiborod
Institutions: Duke University, Duke Medical Center, Saint Luke's Hospital, University of Missouri–Kansas City, Universitätsklinikum des Saarlandes, Saarland University, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, University of Mississippi Medical Center, Baylor Scott & White Research Institute, University of Glasgow, The Heart Research Institute, Yale New Haven Hospital, Yale University, Utrecht University, University Medical Center Utrecht, University of Pennsylvania, University of Lisbon, Centro Académico de Medicina de Lisboa, Unidade Local de Saúde Santa Maria, San Raffaele University of Rome, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele, Vifor Pharma (Switzerland), Universidade da Coruña, Centro de Investigación en Red en Enfermedades Cardiovasculares, Complexo Hospitalario Universitario A Coruña, Instituto de Investigación Biomédica de A Coruña, Medical University of Vienna, Medizinische Hochschule Hannover, Klinikum Braunschweig, University Hospital of Basel, Cliniques Universitaires Saint-Luc, UCLouvain, Queen Mary University of London, William Harvey Research Institute, Federal Union of German Associations of Pharmacists, Freie Universität Berlin, Berlin-Brandenburger Centrum für Regenerative Therapien, German Centre for Cardiovascular Research, Berlin Institute of Health at Charité - Universitätsmedizin Berlin, Charité - Universitätsmedizin Berlin
Language: English
Subfield: Pulmonary and Respiratory Medicine
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
Estimated APC paid: $5,300
OpenAlex ID: W4413100589