Heart Failure

27 Table 17. Strategies to Minimize the Risk of Hyperkalemia in Patients Treated With Aldosterone Antagonists 1. Impaired renal function is a risk factor for hyperkalemia during treatment with aldosterone antagonists. e risk of hyperkalemia increases progressively when serum creatinine is >1.6 mg/dL. a In elderly patients or others with low muscle mass in whom serum creatinine does not accurately reflect glomerular filtration rate, determination that glomerular filtration rate or creatinine clearance is >30 mL/min/1.73 m 2 is recommended. 2. Aldosterone antagonists would not ordinarily be initiated in patients with baseline serum potassium >5.0 mEq/L. 3. An initial dose of spironolactone of 12.5 mg or eplerenone 25 mg is typical, following which the dose may be increased to spironolactone 25 mg or eplerenone 50 mg, if appropriate. 4. e risk of hyperkalemia is increased with concomitant use of higher doses of ACE inhibitors (captopril ≥75 mg daily; enalapril or lisinopril ≥10 mg daily). 5. In most circumstances potassium supplements are discontinued or reduced when initiating aldosterone antagonists. 6. Close monitoring of serum potassium is required; potassium levels and renal function are most typically checked in 3 days and at 1 week aer initiating therapy and at least monthly for the first 3 months. a Although the entry criteria for the trials of aldosterone antagonists included creatinine <2.5 mg/dL, the majority of patients had much lower creatinine; in 1 trial, 95% of patients had creatinine ≤1.7 mg/dL. Drugs of Unproven Value or That May Worsen HF Î Nutritional supplements as treatment for HF are NOT recommended in patients with current or prior symptoms of HFr EF. (III-B: No Benefit) Î Hormonal therapies other than to correct deficiencies are NOT recommended for patients with current or prior symptoms of HFr EF. (III-C: No Benefit) Î Drugs known to adversely affect the clinical status of patients with current or prior symptoms of HFr EF are potentially harmful and should be avoided or withdrawn whenever possible (eg, most antiarrhythmic drugs, most calcium channel–blocking drugs [except amlodipine], nonsteroidal anti-inflammatory drugs, or thiazolidinediones). (III-B: Harm) Î Long-term use of infused positive inotropic drugs is potentially harmful for patients with HFr EF, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage D starting on page 34). (III-C: Harm) Calcium Channel Blockers Î Calcium channel–blocking drugs are NOT recommended as routine treatment for patients with HFr EF. (III-A: No Benefit)

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