Université de Lorraine, Centre d'Investigation Clinique Plurithématique 1433-INSERM-CHRU de Nancy, Inserm U1116 & FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
Division of Cardiology, General Hospital Murska Sobota, Murska Sobota and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
Eur J Heart Fail. 2020 Aug;22(8):1378-1389. doi: 10.1002/ejhf.1793. Epub 2020 Apr 3.
We assessed the interplay between hyperkalaemia (HK) and renin-angiotensin-aldosterone system inhibitor (RAASi) use, dose and discontinuation, and their association with all-cause or cardiovascular death in patients with chronic heart failure (HF). We hypothesized that HK-associated increased death may be related to RAASi withdrawal.
The ESC-HFA-EORP Heart Failure Long-Term Registry was used. Among 9222 outpatients (HF with reduced ejection fraction: 60.6%, HF with mid-range ejection fraction: 22.9%, HF with preserved ejection fraction: 16.5%) from 31 countries, 16.6% had HK (≥5.0 mmol/L) at baseline. Angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) was used in 88.3%, a mineralocorticoid receptor antagonist (MRA) in 58.7%, or a combination in 53.2%; of these, at ≥50% of target dose in ACEi: 61.8%; ARB: 64.7%; and MRA: 90.3%. At a median follow-up of 12.2 months, there were 789 deaths (8.6%). Both hypokalaemia and HK were independently associated with higher mortality, and ACEi/ARB prescription at baseline with lower mortality. MRA prescription was not retained in the model. In multivariable analyses, HK at baseline was independently associated with MRA non-prescription at baseline and subsequent discontinuation. When considering subsequent discontinuation of RAASi (instead of baseline use), HK was no longer found associated with all-cause deaths. Importantly, all RAASi (ACEi, ARB, or MRA) discontinuations were strongly associated with mortality.
In HF, hyper- and hypokalaemia were associated with mortality. However, when adjusting for RAASi discontinuation, HK was no longer associated with mortality, suggesting that HK may be a risk marker for RAASi discontinuation rather than a risk factor for worse outcomes.
我们评估了高钾血症（HK）与肾素-血管紧张素-醛固酮系统抑制剂（RAASi）的使用、剂量和停药之间的相互作用，以及它们与慢性心力衰竭（HF）患者全因或心血管死亡的关系。我们假设与 HK 相关的死亡增加可能与 RAASi 停药有关。
使用 ESC-HFA-EORP 心力衰竭长期注册研究。在来自 31 个国家的 9222 名门诊患者（射血分数降低的心力衰竭：60.6%，射血分数中间范围的心力衰竭：22.9%，射血分数保留的心力衰竭：16.5%）中，16.6%的患者在基线时有 HK（≥5.0mmol/L）。88.3%的患者使用血管紧张素转换酶抑制剂（ACEi）或血管紧张素受体阻滞剂（ARB），58.7%的患者使用盐皮质激素受体拮抗剂（MRA），53.2%的患者联合使用；其中，ACEi 的目标剂量≥50%：61.8%；ARB：64.7%；MRA：90.3%。在中位随访 12.2 个月时，有 789 人死亡（8.6%）。低血钾和 HK 均与死亡率升高独立相关，基线时使用 ACEi/ARB 与死亡率降低相关。MRA 的处方未保留在模型中。多变量分析显示，基线时的 HK 与基线时 MRA 未处方和随后的停药独立相关。当考虑 RAASi 的后续停药（而不是基线使用）时，HK 与全因死亡不再相关。重要的是，所有 RAASi（ACEi、ARB 或 MRA）的停药均与死亡率密切相关。
在 HF 中，高钾血症和低钾血症与死亡率相关。然而，当调整 RAASi 停药时，HK 与死亡率不再相关，这表明 HK 可能是 RAASi 停药的风险标志物，而不是预后不良的危险因素。
