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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: 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.)