Practical guidance on use of potassium binders in the management of hyperkalemia in heart failure

Hello everyone, I'm Clara Bonanad. I'm a cardiologist from Valencia, Spain, and also a professor in the University of Valencia. I'm going to talk about the practical guidance on use of potassium binders in the management of hyperkalemia in heart failure. These are my disclosures and this is the table of contents.

It is well known that there are several subgroups at a higher risk of developing hyperkalemia, but I would like to highlight patients with chronic heart failure in which the frequency could be up to 40% to 50% above all in advanced stages of the disease and on background RAASi and MRA therapy. Until now, we have had an unmet need in our cardiology and our cardiorenal population because we have had a therapeutic dilemma in managing hyperkalemia while optimizing RAASi therapy that is solved with new potassium binders.

Guidelines tell us that we should up-titrate RAASi and MRA to the doses used in clinical trials or to the maximally tolerated dose, but renal dysfunction and hyperkalemia are the major causes not to do it. The American guidelines tell us and recommend us the use of potassium binders, patiromer and sodium zirconium cyclosilicate for the management of hyperkalemia to enable the use and continuation and up-titration of RAASi therapy with a class 2B recommendation. Also, for the first time, these guidelines do not recommend us or do not mention the use of diuretics or low potassium diet to manage hyperkalemia.

What are the reasons that justify the need to optimize treatments in heart failure to reduce reaction fraction despite the risk of hyperkalemia? It's because the four foundational therapies, RAASi and ARNI, beta-blockers, MRA, and SGLT2 inhibitors, the effect of these four medications reduce mortality by 73% in two years and prolong survival for six years. The degree of benefit of each class of drug is independent from each other. Let's initiate them with low doses and progressive increase because that produces benefits of higher magnitude than only up-titration, however, we should deal with the risk of hyperkalemia in certain situations because hyperkalemia in heart failure is a silent killer in chronic heart failure, but also in acute heart failure patients because in this setting, it's associated with higher risk of cardiovascular death, heart failure-related death, and also sudden cardiac death. It's not only a silent killer, but also is a recurrent killer because a heart failure patient who has had an episode of hyperkalemia, will have the risk of developing recurrent hyperkalemia episodes with successively shorter time between them.

Down-titration or discontinuation of RAASi is not the solution because this was associated with doubling of mortality across heart failure patients. In the last years, several expert consensus on heart failure and hyperkalemia in cardiovascular and renal disease have been published, and they tell us that patiromer and sodium zirconium cyclosilicate can be considered and should be considered in heart failure patients with or without CKD to control hyperkalemia in selected patients to allow us the use of RAASi and especially MRA in more patients with higher doses avoiding hyperkalemia. We have to be aware of a value of potassium of 5. 5 mmol/L is a very important value because if we have a patient with an indication to initiate or up-titrate RAASi therapy and he or she has a potassium level above 5, we should use the new potassium binders to up-titrate or initiate RAASi therapy. We should only think and discontinue or reduce RAASi if our patient has a severe hyperkalemia with potassium values above 6.5.

To integrate these potassium binders in our clinical practice, several documents have been published in the last month. You can see in this slide on the right side, a pragmatic algorithm about how to use sodium zirconium cyclosilicate and patiromer in several situations of mild, moderate, severe hyperkalemia and how to deal with hypokalemia. On the left-hand side of this slide, you can see an international Delphi consensus regarding the best practice recommendations for hyperkalemia across the cardiorenal spectrum of patients with more than 500 opinions of cardiologists and nephrologists.

We have to individualize according to countries. This last year, we have been working hard in Spain, and we have started to prescribe potassium binders despite some difficulties we may face related to the visa and we also are working hard in expanding the use of this great therapeutical opportunity with several multidisciplinary consensus and meetings.

To integrate these new potassium binders in our clinical daily practice, we need three things. First of all, we need real-world data. In this slide, you can see three articles about real-world data. The first one about sodium zirconium cyclosilicate in hemodialyzed patients. The second one, a case series of heart failure patients treated with sodium zirconium cyclosilicate. The third one, the first experience in Spain with a patiromer in hyperkalemia and heart failure patients. The second thing we need, as you can see in this slide, that is a picture of my hospital, is the availability of these drugs in our hospitals. On the right hand of this slide, you can see that I have sodium zirconium cyclosilicate available in the emergency department in my hospital. The third thing and most important thing is to get out of your comfort zone. You can see on the left side of this slide, a prescription of mine in a patient admitted in our cardiology department with heart failure that is an hemodialyzed patient treated with resins, and I have changed the resin to sodium zirconium cyclosilicate at discharge, so please get out of your comfort zone.

To end my presentation, I wanted to show you this multidisciplinary meeting that took off in Valencia, Spain, with more than 300 assistants, also supported by several Spanish societies and also supported by Harvard and Leicester University, that was a very successful meeting. We think that multidisciplinary teams and meetings that treat cardiorenal patients should be formalized to improve our quality of practice.

To conclude, hyperkalemia is common in heart failure and is a silent and recurrent killer. There was an unmet necessity in optimization RAASi, but new potassium binders can solve it. Time is not goal, time is life. Get out please of your comfort zone and give the best to your patients and multidisciplinary teamwork and meetings will help us to walk towards excellence.

Thank you very much for your attention.