Management of RAASi-associated hyperkalemia in patients with cardiovascular disease

José Silva-Cardoso, Dulce Brito, João Miguel Frazão, Aníbal Ferreira, Paulo Bettencourt, Patrícia Branco, Cândida Fonseca

Research output: Contribution to journalReview articlepeer-review

10 Citations (Scopus)
21 Downloads (Pure)


Renin–angiotensin–aldosterone system inhibitors (RAASi) reduce morbidity and mortality in heart failure (HF) with reduced ejection fraction in a dose-dependent manner. They also have a positive impact in other cardiovascular diseases (CVDs). However, RAASi may induce hyperkalemia, a potentially life-threatening disorder. This risk is further increased in those with concomitant chronic kidney disease, diabetes mellitus, and/or in patients with hypertension. Current treatment guidelines recommend maximal RAASi dosing to improve clinical outcomes; however, this is often limited by the development of hyperkalemia. When this occurs, current guidelines recommend RAASi down-titration/interruption, which, while improving short-term prognosis, is associated with a negative long-term prognostic impact. At present, the European Society of Cardiology suggests the consideration of novel potassium binders (patiromer and sodium zirconium cyclosilicate) for the management of RAASi-associated hyperkalemia. Both drugs can reduce serum potassium levels and prevent recurrent hyperkalemia. Additionally, patiromer showed enabling of RAASi optimization in high-risk patients. Nevertheless, precise recommendations on the use of these drugs are lacking. Building upon current HF guideline recommendations, a multidisciplinary expert panel convened to design an algorithm providing practical guidance on the use of novel potassium binders/patiromer in patients with HF and/or other CVD. As a result of that effort, we present an evidence-based treatment algorithm for the management of hyperkalemia with novel potassium binders/patiromer in patients with HF and/or other CVD receiving RAASi, including the necessary monitoring to avoid induction of hypokalemia. This algorithm aims to maintain or up-titrate RAASi to optimized doses, while maintaining normokalemia, improved clinical outcomes, and long-term prognosis.

Original languageEnglish
Pages (from-to)891 - 896
JournalHeart Failure Reviews
Issue number4
Early online dateFeb 2021
Publication statusPublished - Jul 2021


  • Heart failure with reduced ejection fraction
  • Hyperkalemia
  • Novel potassium binders
  • RAASi optimization
  • Renin–angiotensin–aldosterone system inhibitors


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