{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,1]],"date-time":"2026-05-01T10:54:50Z","timestamp":1777632890383,"version":"3.51.4"},"reference-count":15,"publisher":"Springer Science and Business Media LLC","issue":"4","license":[{"start":{"date-parts":[[2021,2,18]],"date-time":"2021-02-18T00:00:00Z","timestamp":1613606400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2021,2,18]],"date-time":"2021-02-18T00:00:00Z","timestamp":1613606400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Heart Fail Rev"],"published-print":{"date-parts":[[2021,7]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:p>Renin\u2013angiotensin\u2013aldosterone 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.<\/jats:p>","DOI":"10.1007\/s10741-020-10069-3","type":"journal-article","created":{"date-parts":[[2021,2,19]],"date-time":"2021-02-19T16:49:23Z","timestamp":1613753363000},"page":"891-896","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":28,"title":["Management of RAASi-associated hyperkalemia in patients with cardiovascular disease"],"prefix":"10.1007","volume":"26","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9774-9864","authenticated-orcid":false,"given":"Jos\u00e9","family":"Silva-Cardoso","sequence":"first","affiliation":[]},{"given":"Dulce","family":"Brito","sequence":"additional","affiliation":[]},{"given":"Jo\u00e3o Miguel","family":"Fraz\u00e3o","sequence":"additional","affiliation":[]},{"given":"An\u00edbal","family":"Ferreira","sequence":"additional","affiliation":[]},{"given":"Paulo","family":"Bettencourt","sequence":"additional","affiliation":[]},{"given":"Patr\u00edcia","family":"Branco","sequence":"additional","affiliation":[]},{"given":"C\u00e2ndida","family":"Fonseca","sequence":"additional","affiliation":[]}],"member":"297","published-online":{"date-parts":[[2021,2,18]]},"reference":[{"issue":"27","key":"10069_CR1","doi-asserted-by":"publisher","first-page":"2129","DOI":"10.1093\/eurheartj\/ehw128","volume":"37","author":"Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, Gonz\u00e1lez-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P, ESC Scientific Document Group","year":"2016","unstructured":"Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, Falk V, Gonz\u00e1lez-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GMC, Ruilope LM, Ruschitzka F, Rutten FH, van der Meer P, ESC Scientific Document Group (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J 37(27):2129\u20132200. https:\/\/doi.org\/10.1093\/eurheartj\/ehw128","journal-title":"Eur Heart J"},{"issue":"3","key":"10069_CR2","doi-asserted-by":"publisher","first-page":"180","DOI":"10.1093\/ehjcvp\/pvy015","volume":"4","author":"GMC Rosano","year":"2018","unstructured":"Rosano GMC, Tamargo J, Kjeldsen KP, Lainscak M, Agewall S, Anker SD, Ceconi C, Coats AJS, Drexel H, Filippatos G, Kaski JC, Lund L, Niessner A, Ponikowski P, Savarese G, Schmidt TA, Seferovic P, Wassmann S, Walther T, Lewis BS (2018) Expert consensus document on the management of hyperkalaemia in patients with cardiovascular disease treated with renin angiotensin aldosterone system inhibitors: coordinated by the Working Group on Cardiovascular Pharmacotherapy of the European Society of Cardiology. Eur Heart J Cardiovasc Pharmacother 4(3):180\u2013188. https:\/\/doi.org\/10.1093\/ehjcvp\/pvy015","journal-title":"Eur Heart J Cardiovasc Pharmacother"},{"issue":"14","key":"10069_CR3","doi-asserted-by":"publisher","first-page":"1575","DOI":"10.1016\/j.jacc.2016.06.060","volume":"68","author":"CM Sarwar","year":"2016","unstructured":"Sarwar CM, Papadimitriou L, Pitt B, Pina I, Zannad F, Anker SD, Gheorghiade M, Butler J (2016) Hyperkalemia in heart failure. J Am Coll Cardiol 68(14):1575\u20131589. https:\/\/doi.org\/10.1016\/j.jacc.2016.06.060","journal-title":"J Am Coll Cardiol"},{"issue":"4","key":"10069_CR4","doi-asserted-by":"publisher","first-page":"573","DOI":"10.1161\/circheartfailure.114.001104","volume":"7","author":"Vardeny O, Claggett B, Anand I, Rossignol P, Desai AS, Zannad F, Pitt B, Solomon SD, Randomized Aldactone Evaluation Study Investigators","year":"2014","unstructured":"Vardeny O, Claggett B, Anand I, Rossignol P, Desai AS, Zannad F, Pitt B, Solomon SD, Randomized Aldactone Evaluation Study Investigators (2014) Incidence, predictors, and outcomes related to hypo- and hyperkalemia in patients with severe heart failure treated with a mineralocorticoid receptor antagonist. Circ Heart Fail 7(4):573\u2013579. https:\/\/doi.org\/10.1161\/circheartfailure.114.001104","journal-title":"Circ Heart Fail"},{"issue":"3","key":"10069_CR5","doi-asserted-by":"publisher","first-page":"213","DOI":"10.1159\/000479802","volume":"46","author":"AJ Collins","year":"2017","unstructured":"Collins AJ, Pitt B, Reaven N, Funk S, McGaughey K, Wilson D, Bushinsky DA (2017) Association of serum potassium with all-cause mortality in patients with and without heart failure, chronic kidney disease, and\/or diabetes. Am J Nephrol 46(3):213\u2013221. https:\/\/doi.org\/10.1159\/000479802","journal-title":"Am J Nephrol"},{"issue":"9","key":"10069_CR6","doi-asserted-by":"publisher","first-page":"517","DOI":"10.1016\/j.repc.2020.03.015","volume":"39","author":"C Fonseca","year":"2020","unstructured":"Fonseca C, Brito D, Branco P, Fraz\u00e3o J, Silva-Cardoso J, Bettencourt P (2020) Hyperkalemia and management of renin-angiotensin-aldosterone system inhibitors in chronic heart failure and systolic dysfunction: a systematic review. Rev Port Cardiol 39(9):517\u2013541. https:\/\/doi.org\/10.1016\/j.repc.2020.03.015","journal-title":"Rev Port Cardiol"},{"issue":"9","key":"10069_CR7","doi-asserted-by":"publisher","first-page":"1326","DOI":"10.1002\/ejhf.1182","volume":"20","author":"G Savarese","year":"2018","unstructured":"Savarese G, Carrero JJ, Pitt B, Anker SD, Rosano GMC, Dahlstrom U, Lund LH (2018) Factors associated with underuse of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction: an analysis of 11 215 patients from the Swedish Heart Failure Registry. Eur J Heart Fail 20(9):1326\u20131334. https:\/\/doi.org\/10.1002\/ejhf.1182","journal-title":"Eur J Heart Fail"},{"issue":"11 Suppl","key":"10069_CR8","first-page":"S212","volume":"21","author":"M Epstein","year":"2015","unstructured":"Epstein M, Reaven NL, Funk SE, McGaughey KJ, Oestreicher N, Knispel J (2015) Evaluation of the treatment gap between clinical guidelines and the utilization of renin-angiotensin-aldosterone system inhibitors. Am J Manag Care 21(11 Suppl):S212-220","journal-title":"Am J Manag Care"},{"issue":"8","key":"10069_CR9","doi-asserted-by":"publisher","first-page":"1217","DOI":"10.1002\/ejhf.1199","volume":"20","author":"M Trevisan","year":"2018","unstructured":"Trevisan M, de Deco P, Xu H, Evans M, Lindholm B, Bellocco R, Barany P, Jernberg T, Lund LH, Carrero JJ (2018) Incidence, predictors and clinical management of hyperkalaemia in new users of mineralocorticoid receptor antagonists. Eur J Heart Fail 20(8):1217\u20131226. https:\/\/doi.org\/10.1002\/ejhf.1199","journal-title":"Eur J Heart Fail"},{"issue":"5","key":"10069_CR10","doi-asserted-by":"publisher","first-page":"923","DOI":"10.1002\/ejhf.1079","volume":"20","author":"JC Beusekamp","year":"2018","unstructured":"Beusekamp JC, Tromp J, van der Wal HH, Anker SD, Cleland JG, Dickstein K, Filippatos G, van der Harst P, Hillege HL, Lang CC, Metra M, Ng LL, Ponikowski P, Samani NJ, van Veldhuisen DJ, Zwinderman AH, Rossignol P, Zannad F, Voors AA, van der Meer P (2018) Potassium and the use of renin-angiotensin-aldosterone system inhibitors in heart failure with reduced ejection fraction: data from BIOSTAT-CHF. Eur J Heart Fail 20(5):923\u2013930. https:\/\/doi.org\/10.1002\/ejhf.1079","journal-title":"Eur J Heart Fail"},{"issue":"21","key":"10069_CR11","doi-asserted-by":"publisher","first-page":"2223","DOI":"10.1001\/jama.2014.15688","volume":"312","author":"M Kosiborod","year":"2014","unstructured":"Kosiborod M, Rasmussen HS, Lavin P, Qunibi WY, Spinowitz B, Packham D, Roger SD, Yang A, Lerma E, Singh B (2014) Effect of sodium zirconium cyclosilicate on potassium lowering for 28 days among outpatients with hyperkalemia: the HARMONIZE randomized clinical trial. JAMA 312(21):2223\u20132233. https:\/\/doi.org\/10.1001\/jama.2014.15688","journal-title":"JAMA"},{"key":"10069_CR12","doi-asserted-by":"publisher","unstructured":"Bakris GL, Pitt B, Weir MR, Freeman MW, Mayo MR, Garza D, Stasiv Y, Zawadzki R, Berman L, Bushinsky DA, AMETHYST-DN Investigators (2015) Effect of patiromer on serum potassium level in patients with hyperkalemia and diabetic kidney disease: the AMETHYST-DN randomized clinical trial. JAMA 314(2):151\u2013161. https:\/\/doi.org\/10.1001\/jama.2015.7446","DOI":"10.1001\/jama.2015.7446"},{"key":"10069_CR13","doi-asserted-by":"publisher","unstructured":"Pitt B, Anker SD, Bushinsky DA, Kitzman DW, Zannad F, Huang IZ, PEARL-HF Investigators (2011) Evaluation of the efficacy and safety of RLY5016, a polymeric potassium binder, in a double-blind, placebo-controlled study in patients with chronic heart failure (the PEARL-HF) trial. Eur Heart J 32(7):820\u2013828. https:\/\/doi.org\/10.1093\/eurheartj\/ehq502","DOI":"10.1093\/eurheartj\/ehq502"},{"issue":"10208","key":"10069_CR14","doi-asserted-by":"publisher","first-page":"1540","DOI":"10.1016\/s0140-6736(19)32135-x","volume":"394","author":"R Agarwal","year":"2019","unstructured":"Agarwal R, Rossignol P, Romero A, Garza D, Mayo MR, Warren S, Ma J, White WB, Williams B (2019) Patiromer versus placebo to enable spironolactone use in patients with resistant hypertension and chronic kidney disease (AMBER): a phase 2, randomised, double-blind, placebo-controlled trial. Lancet 394(10208):1540\u20131550. https:\/\/doi.org\/10.1016\/s0140-6736(19)32135-x","journal-title":"Lancet"},{"key":"10069_CR15","doi-asserted-by":"publisher","unstructured":"Seferovic PM, Ponikowski P, Anker SD, Bauersachs J, Chioncel O, Cleland JGF, de Boer RA, Drexel H, Ben Gal T, Hill L, Jaarsma T, Jankowska EA, Anker MS, Lainscak M, Lewis BS, McDonagh T, Metra M, Milicic D, Mullens W, Piepoli MF, Rosano G, Ruschitzka F, Volterrani M, Voors AA, Filippatos G, Coats AJS (2019) Clinical practice update on heart failure 2019: Pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 21(10):1169\u20131186. https:\/\/doi.org\/10.1002\/ejhf.1531","DOI":"10.1002\/ejhf.1531"}],"container-title":["Heart Failure Reviews"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10741-020-10069-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s10741-020-10069-3\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s10741-020-10069-3.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,5,25]],"date-time":"2021-05-25T05:30:30Z","timestamp":1621920630000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s10741-020-10069-3"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,2,18]]},"references-count":15,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2021,7]]}},"alternative-id":["10069"],"URL":"https:\/\/doi.org\/10.1007\/s10741-020-10069-3","relation":{},"ISSN":["1382-4147","1573-7322"],"issn-type":[{"value":"1382-4147","type":"print"},{"value":"1573-7322","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,2,18]]},"assertion":[{"value":"13 December 2020","order":1,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"18 February 2021","order":2,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Jos\u00e9 Silva-Cardoso has received speaker and consultant fees, or advisory board participation fees, or investigational grants from Abbott, AstraZeneca Pharmaceuticals, Bial, Boehringer Ingelheim, Menarini, Merck Serono, Merck Sharp & Dohme, Novartis, Orion, Pfizer, Sanofi, Servier, and Vifor Pharma. Dulce Brito has received speaker and consultant fees or investigational grants from AstraZeneca Pharmaceuticals, Boehringer Ingelheim, Novartis, Orion, Pfizer, Roche Diagnostics, Sanofi, Servier, and Vifor Pharma. Jo\u00e3o Miguel Fraz\u00e3o has received speaker and consultant fees from Amgen Biopharmaceuticals and Vifor Pharma. An\u00edbal Ferreira has received speaker and consultant fees or investigational grants from Amgen Biopharmaceuticals, Astellas, Boehringer Ingelheim, Mundipharma, Sanofi, Shire, Vifor Pharma. Paulo Bettencourt has received speaker and consultant fees from OM PHARMA, Servier, and AstraZeneca and an investigational grant from Roche Diagnostics. Patr\u00edcia Branco has received speaker and consultant fees from AstraZeneca Pharmaceuticals, Bayer, Baxter, Boehringer Ingelheim, Medtronic, Mundipharma, and Vifor Pharma. C\u00e2ndida Fonseca has received speaker and consultant fees, or investigational grants, from AstraZeneca Pharmaceuticals, Bayer, Boehringer Ingelheim, Merck Serono, Novartis, Orion, Pfizer, Sanofi, Servier, and Vifor Pharma.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}}]}}