Beavers Craig J, Greene Stephen J
University of Kentucky College of Pharmacy, Lexington, KY, USA.
Duke Clinical Research Institute, Durham, NC, USA.
Heart Fail Rev. 2025 Aug 22. doi: 10.1007/s10741-025-10549-4.
Hyperkalemia is a potentially life-threatening electrolyte imbalance that has traditionally posed significant challenges in the management of heart failure (HF). This review explores the complex interplay between hyperkalemia and the use of guideline-directed medical therapies (GDMT), such as renin-angiotensin-aldosterone system inhibitors (RAASi) and steroidal mineralocorticoid receptor antagonists (sMRAs), including spironolactone and eplerenone, which are currently recommended in guidelines for improving outcomes in heart failure with reduced ejection fraction (HFrEF). While these therapies reduce mortality and hospitalizations in HFrEF, their benefit in patients with heart failure with left ventricular ejection fraction (LVEF) ≥ 40% remains less conclusive. Nevertheless, their use in clinical practice is often limited by the risk of hyperkalemia, potentially leading to dose reduction or discontinuation of life-saving treatments. The prevalence of hyperkalemia in HF patients is notably higher compared to the general population, particularly in those with comorbid chronic kidney disease (CKD) and diabetes mellitus, further complicating management. This review emphasizes the importance of regular potassium monitoring, the potential benefits of combining therapies such as sodium-glucose cotransporter 2 (SGLT2) inhibitors with RAASi to reduce the risk of hyperkalemia, and the emergence of the newer non-steroidal MRA (nsMRA), finerenone, which may have a lower risk of hyperkalemia. Additionally, potassium binders such as patiromer and sodium zirconium cyclosilicate (SZC) are highlighted for their role in managing and preventing hyperkalemia, allowing patients to continue optimal RAASi and MRA therapy without interruption. By synthesizing current evidence on the incidence, risks, and management strategies of hyperkalemia in HF, this review aims to provide a comprehensive guide for clinicians to optimize patient outcomes while mitigating the risks associated with hyperkalemia.
高钾血症是一种可能危及生命的电解质失衡，传统上在心力衰竭（HF）的管理中带来了重大挑战。本综述探讨了高钾血症与指南指导的药物治疗（GDMT）之间的复杂相互作用，如肾素 - 血管紧张素 - 醛固酮系统抑制剂（RAASi）和甾体类盐皮质激素受体拮抗剂（sMRAs），包括螺内酯和依普利酮，目前这些药物在射血分数降低的心力衰竭（HFrEF）改善预后指南中被推荐使用。虽然这些疗法可降低HFrEF患者的死亡率和住院率，但它们在左心室射血分数（LVEF）≥40%的心力衰竭患者中的益处仍不太明确。然而，它们在临床实践中的使用常常受到高钾血症风险的限制，这可能导致减少剂量或停用挽救生命的治疗。与普通人群相比，HF患者中高钾血症的患病率显著更高，尤其是在合并慢性肾脏病（CKD）和糖尿病的患者中，这进一步使管理复杂化。本综述强调了定期监测血钾的重要性、联合使用钠 - 葡萄糖协同转运蛋白2（SGLT2）抑制剂与RAASi等疗法以降低高钾血症风险的潜在益处，以及新型非甾体类盐皮质激素受体拮抗剂（nsMRA）非奈利酮的出现，其高钾血症风险可能较低。此外，还强调了帕替罗姆和环硅酸钠锆（SZC）等钾结合剂在管理和预防高钾血症中的作用，使患者能够持续接受最佳的RAASi和MRA治疗而不受干扰。通过综合当前关于HF中高钾血症的发生率、风险和管理策略的证据，本综述旨在为临床医生提供全面指导，以优化患者预后，同时降低与高钾血症相关的风险。
