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Introduction and objectives: Neurohormonal blockade (NB)/modulation is the combination of two renin-angiotensin-aldosterone system inhibitors (RAASi) with a beta blocker. It is the core therapy for heart failure with reduced ejection fraction (HFrEF). While improving long term prognosis, it also induces hyperkalemia (serum K+ >5.0 mEq/L) due to RAASi effects. This may cause lethal arrhythmias and increase mortality in the short term. Thus, hyperkalemia frequently leads to withholding or reducing the intensity of neurohormonal blockade/modulation, which is associated with worsening long term prognosis. We assessed the relevance of hyperkalemia as a limiting factor of neurohormonal blockade/modulation in real life clinical conditions. Methods: We reviewed the medical records of HFrEF patients attending a HF clinic at a tertiary Portuguese hospital during 2018 (n=240). The number of patients not tolerating maximal neurohormonal blockade/modulation due to hyperkalemia was determined. The incidence and characteristics of hyperkalemia episodes were also assessed. Results: Only six patients (3%) achieved maximal doses of neurohormonal blockade/modulation. Hyperkalemia was the limiting factor in 48 (20%) patients. A total of 185 hyperkalemia episodes occurred in 100 (42%) patients. Forty-five (24%) episodes were moderate or severe (serum K+ >5.5 mEq/L). In these HFrEF patients, the co-existence of hypertension, diabetes or renal failure was associated with the occurrence of hyperkalemia. Conclusions: In daily clinical practice, hyperkalemia is frequent and limits neurohormonal blockade/modulation by leading to the withholding or reducing of the intensity of RAAS inhibition. Considering the negative prognostic impact associated with sub-optimal neurohormonal blockade/modulation, addressing hyperkalemia is an important issue when treating HFrEF patients. Resumo: Introdução e objetivos: O bloqueio/modulação neuro-hormonal (BMNH) é a combinação de dois inibidores (i) do sistema Renina-Angiotensina-Aldosterona (RAAS) com um betabloqueador. Como principal terapêutica na insuficiência cardíaca (IC) com fração de ejeção reduzida (FEr), melhora o prognóstico em longo prazo, porém induz hipercaliemia (K+ sérico >5,0 mEq/L), pode causar arritmias letais e aumentar a mortalidade em curto prazo. A hipercaliemia evita ou reduz frequentemente a intensidade do BMNH, o que está associado a pior prognóstico em longo prazo. Avaliámos a relevância da hipercaliemia como fator limitante do BMNH em condições clínicas da vida real. Métodos: Reviram-se os registos médicos dos doentes com ICFEr num hospital terciário português em 2018 (n=240). Determinou-se o número de doentes sem tolerância de BMNH máximo por hipercaliemia e avaliou-se as incidências/características dos episódios de hipercaliemia. Resultados: Apenas seis doentes (3%) atingiram doses máximas de BMNH. A hipercaliemia foi o fator limitante em 48 (20%) doentes. Ocorreram 185 episódios de hipercaliemia em 100 (42%) doentes. Destes, 45 (24%) foram moderados ou graves (K+ sérico >5,5 mEq/L). A coexistência de hipertensão, diabetes ou insuficiência renal foi associada à ocorrência de hipercaliemia. Conclusões: Na prática clínica, a hipercaliemia é frequente e limita o BMNH, evitando ou reduzindo a intensidade da inibição de RAAS. Considerando o impacto prognóstico negativo associado ao BMNH subótimo, a abordagem da hipercaliemia é uma questão importante no tratamento de doentes com ICFEr.

Introduction and Objectives: Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). RAASi optimization in real-life care is challenged by hyperkalemia, a potentially fatal adverse event, which can necessitate downtitration or discontinuation of RAASi and negatively impact survival in HFrEF. The literature on this problem is sparse. We performed a systematic review of studies on HFrEF to investigate the prevalence, incidence, and risk factors of hyperkalemia, RAASi prescription rates, frequency of RAASi downtitration or discontinuation due to hyperkalemia, and the potential negative effect of the latter on prognosis. Methods: We conducted a MEDLINE (PubMed) search including observational and interventional studies published between January 1987 and May 2018. Results: A total of 30 observational and 18 interventional studies were included in the review. The incidence of hyperkalemia reported was between 0% and 63% in observational studies and was between 0% and 30% in clinical trials. Risk factors for hyperkalemia included RAASi prescription, older age, diabetes, and chronic kidney disease. In real-life studies, RAASi were downtitrated or discontinued in 3-22% of HFrEF patients; hyperkalemia was the reported cause in 5% of cases. No reports were found on the impact on prognosis of RAASi downtitration or discontinuation due to hyperkalemia. Conclusions: Hyperkalemia and RAASi downtitration or discontinuation are frequent, particularly in real-life HFrEF studies. Further research is needed to clarify the role of RAASi downtitration or discontinuation due to hyperkalemia and to assess its long-term prognostic impact in HFrEF patients. Resumo: Introdução e objetivos: Os inibidores do sistema renina-angiotensina-aldosterona (iSRAA) constituem pedras basilares para o tratamento da insuficiência cardíaca com fração de ejeção reduzida (IC-FER). A otimização dos iSRAA é dificultada pela ocorrência de hipercalemia, que obriga à redução/interrupção do iSRAA, podendo impactar negativamente na sobrevivência dos doentes com IC-FER. Esta questão é raramente abordada na literatura. Métodos: Realizámos uma revisão sistemática dos estudos sobre doentes com IC-FER para investigar a prevalência, incidência e fatores de risco para hipercaliemia, frequência de utilização de iSRAA, frequência de redução/interrupção dos iSRAA por hipercaliemia e o possível impacto negativo da redução/interrupção dos iSRAA no prognóstico. A pesquisa foi feita na Medline (PubMed) incluindo estudos observacionais e interventivos publicados entre janeiro de 1987 e maio de 2018. Resultados: Foram incluídos 30 estudos observacionais e 18 interventivos. A frequência relatada de hipercalemia variou entre 0% e 63% em estudos observacionais e entre 0% e 30% em ensaios clínicos. Fatores de risco para hipercalemia incluíram uso de iSRAA, idade avançada, diabetes e doença renal crónica. Em estudos de vida real, os iSRAA foram interrompidos em 3% a 22% dos doentes com IC-FER, sendo a hipercalemia a causa em 5% destes casos. Não foram encontrados relatos do impacto prognóstico da redução/interrupção dos iSRAA devida à hipercalemia. Conclusões: A hipercaliemia e redução/interrupção dos iSRAA são frequentes, principalmente em estudos de vida real de IC-FER. Novos estudos serão necessários para esclarecer o papel da redução/interrupção dos iSRAA devida a hipercalemia e para avaliar o seu impacto prognóstico a longo prazo em doentes com IC-FER.

Introduction: Hyperkalemia (HK) is a common electrolyte disorder in chronic kidney disease (CKD), mainly in the advanced stages. A positive potassium balance due to reduced renal excretory capacity is likely the main pathogenic mechanism of HK. Research into the relative role of each pathogenic element in the development of HK in CKD may help to implement more suitable therapies. Objective: To investigate renal potassium handling in advanced CKD patients, and to determine the differences between patients with or without HK. Material and methods: Cross-sectional observational study in adult patients with stage 4–5 CKD pre-dialysis. Selection criteria included clinically stable patients and the ability to collect a 24 h urine sample correctly. Blood and urinary biochemical parameters were analyzed including sodium and potassium (K). Fractional excretion of K (FEK) and K load relative to glomerular filtration (Ku/GFR) were calculated. HK was defined as a serum K concentration ≥5.5 mmol/l. Results: The study group consisted of 212 patients (mean age 65 ± 14 years, 92 females) with a mean GFR of 15.0 ± 4.2 mL/min/1.73 m2. 63 patients (30%) had HK. Patients with HK had lower mean bicarbonate levels with respect to patients with normal K levels (NK) (20.3 ± 3.1 vs. 22.8 ± 3.2 mEq/l, P

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El potasio es el principal catión intracelular y es el determinante del potencial de reposo de la célula. Por esta razón, la hipercaliemia, frecuentemente, pero no siempre asociada a la insuficiencia renal severa, es una entidad potencialmente fatal por su capacidad para generar arritmias. En el tratamiento agudo mientras se realiza la terapia dialítica, hay varias opciones terapéuticas destinadas a estabilizar la membrana y a redistribuir el potasio hacia la célula. En esta última modalidad de tratamiento se ubica la insulina que disminuye los niveles de potasio de una forma rápida aunque transitoria. No obstante, la forma de administración de la insulina varía ampliamente según escuelas de formación, la disponibilidad de recursos y el conocimiento del médico.

Introduction and Objectives: Neurohormonal blockade (NB)/modulation is the combination of two renin-angiotensin-aldosterone system inhibitors (RAASi) with a beta blocker. It is the core therapy for heart failure with reduced ejection fraction (HFrEF). While improving long term prognosis, it also induces hyperkalemia (serum K + >5.0 mEq/L) due to RAASi effects. This may cause lethal arrhythmias and increase mortality in the short term. Thus, hyperkalemia frequently leads to withholding or reducing the intensity of neurohormonal blockade/modulation, which is associated with worsening long term prognosis. We assessed the relevance of hyperkalemia as a limiting factor of neurohormonal blockade/modulation in real life clinical conditions., Methods: We reviewed the medical records of HFrEF patients attending a HF clinic at a tertiary Portuguese hospital during 2018 (n=240). The number of patients not tolerating maximal neurohormonal blockade/modulation due to hyperkalemia was determined. The incidence and characteristics of hyperkalemia episodes were also assessed., Results: Only six patients (3%) achieved maximal doses of neurohormonal blockade/modulation. Hyperkalemia was the limiting factor in 48 (20%) patients. A total of 185 hyperkalemia episodes occurred in 100 (42%) patients. Forty-five (24%) episodes were moderate or severe (serum K + >5.5 mEq/L). In these HFrEF patients, the co-existence of hypertension, diabetes or renal failure was associated with the occurrence of hyperkalemia., Conclusions: In daily clinical practice, hyperkalemia is frequent and limits neurohormonal blockade/modulation by leading to the withholding or reducing of the intensity of RAAS inhibition. Considering the negative prognostic impact associated with sub-optimal neurohormonal blockade/modulation, addressing hyperkalemia is an important issue when treating HFrEF patients., (Copyright © 2022 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objective: Evaluate if there is a direct relationship between the way of administration of heparin and the presence of hemodynamic and hydroelectrolitic changes in patients who underwent revascularization surgery in the Instituto Nacional de Cardiología «Ignacio Chávezraquo;. Methods: 26 patients were included in this study underwent revascularization surgery with extracorporeal circulation. Group DB we give 300 U/kg of heparin in bolus through the central catheter. Group DF we give 300 U/kg of fractionated heparin in three equivalent doses with an interval of one minute through of central catheter. A measurement of CO, CI, SVR, PVR, MPP, HR, MAP, potassium and seric calcium by five minutes before administrating the doses and three minutes after, and of activated coagulation time before and after heparin. Results: It was not found significant difference between both groups in gender, age, weight, height, body mass index, superficial corporeal area, LVEF and CARE scale. A decrease of the SVR and MAP was found posterior to the administration in bolus of the dose of heparin p = 0.04, p = 0.002, an increase of serum potassium after the administration in bolus of heparin was found p = 0.005. Conclusions: The administration in bolus of heparine in high doses has important vasodilating properties. [ABSTRACT FROM AUTHOR]

Introduction: The impact of the immediate in-hospital post-resuscitation care after out-hospital cardiac arrest is not well known. Based on treatment variables and laboratory findings a multiple logistic regression model was created for the prediction of survival at 6 months from the event. Materials and methods: A retrospective study of the hospital charts of patients successfully resuscitated and treated in one of three community hospitals from 1998 to 2000. In addition to several pre-hospital variables, the mean 72 h values of clinical features such as blood pressure, blood glucose concentration and initiated treatment used, were included in a forward multiple logistic regression model predicting survival at 6 months from the event. Results: The charts of 98 out of a total of 102 patients were sufficiently complete and included in the analysis. Variables independently associated with survival were age, delay before a return of spontaneous circulation, mean blood glucose and serum potassium, and the use of beta-blocking agents during post-resuscitation care. When those patients who were assigned a ‘do not attempt to resuscitate’ (DNAR) order during the first 72 h of treatment were excluded from the analysis blood glucose, blood potassium and the use beta-blocking agents remained independently associated with survival. Conclusion: This study suggests that in-hospital factors are associated with survival from out-of-hospital cardiac arrest. The mean blood glucose and serum potassium during the first 72 h of treatment and the use of beta-blocking agents were significantly and independently associated with survival. [Copyright &y& Elsevier]

Introduction and Objectives: Renin-angiotensin-aldosterone system inhibitors (RAASi) are the cornerstone of treatment of heart failure with reduced ejection fraction (HFrEF). RAASi optimization in real-life care is challenged by hyperkalemia, a potentially fatal adverse event, which can necessitate downtitration or discontinuation of RAASi and negatively impact survival in HFrEF. The literature on this problem is sparse. We performed a systematic review of studies on HFrEF to investigate the prevalence, incidence, and risk factors of hyperkalemia, RAASi prescription rates, frequency of RAASi downtitration or discontinuation due to hyperkalemia, and the potential negative effect of the latter on prognosis., Methods: We conducted a MEDLINE (PubMed) search including observational and interventional studies published between January 1987 and May 2018., Results: A total of 30 observational and 18 interventional studies were included in the review. The incidence of hyperkalemia reported was between 0% and 63% in observational studies and was between 0% and 30% in clinical trials. Risk factors for hyperkalemia included RAASi prescription, older age, diabetes, and chronic kidney disease. In real-life studies, RAASi were downtitrated or discontinued in 3-22% of HFrEF patients; hyperkalemia was the reported cause in 5% of cases. No reports were found on the impact on prognosis of RAASi downtitration or discontinuation due to hyperkalemia., Conclusions: Hyperkalemia and RAASi downtitration or discontinuation are frequent, particularly in real-life HFrEF studies. Further research is needed to clarify the role of RAASi downtitration or discontinuation due to hyperkalemia and to assess its long-term prognostic impact in HFrEF patients., (Copyright © 2020 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

Introduction: Hyperkalemia (HK) is a common electrolyte disorder in chronic kidney disease (CKD), mainly in the advanced stages. A positive potassium balance due to reduced renal excretory capacity is likely the main pathogenic mechanism of HK. Research into the relative role of each pathogenic element in the development of HK in CKD may help to implement more suitable therapies., Objective: To investigate renal potassium handling in advanced CKD patients, and to determine the differences between patients with or without HK., Material and Methods: Cross-sectional observational study in adult patients with stage 4-5 CKD pre-dialysis. Selection criteria included clinically stable patients and the ability to collect a 24hour urine sample correctly. Blood and urinary biochemical parameters were analysed including sodium and potassium (K). Fractional excretion of K (FEK) and K load relative to glomerular filtration (Ku/GFR) were calculated. HK was defined as a serum K concentration ≥5.5mmol/l., Results: The study group consisted of 212 patients (mean age 65±14 years, 92 females) with a mean GFR of 15.0±4.2ml/min/1.73m 2 . 63 patients (30%) had HK. Patients with HK had lower mean bicarbonate levels with respect to patients with normal K levels (NK) (20.3±3.1 vs. 22.8±3.2 mEq/l, P<.0001), but no differences were noted in total urinary sodium and K excretion. While mean FEK values were lower in patients with HK (32.1±12.1% vs. 36.4±14.3%, P=.038), Ku/GFR values were significantly greater with respect to the NK subgroup (4.2±1.5 vs. 3.7±1.4 mmol/ml/min, P=0,049). FEK showed a strong linear correlation with Ku/GFR (R 2 =0.74), and partial linear regressions demonstrated that at a similar Ku/GFR level, the FEK of patients with HK was lower than that of NK patients. By multivariate linear and logistic regression analyses, both FEK and Ku/GFR were shown to be the main determinants of K serum levels and HK., Conclusions: Although the K load relative to glomerular filtration (Ku/GFR) is an important determinant of HK in advanced CKD, the most noteworthy characteristic associated with HK in these patients was the limitation of compensatory urinary K excretion, as indicated by lower FEK., (Copyright © 2019 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)