What is the best treatment for a patient with hypertension and congestive heart failure (CHF) with a reduced ejection fraction (EF) and hyperkalemia?

Treatment for Hypertension with Hyperkalemia and HFrEF

For a patient with hypertension, hyperkalemia (K 5.3), and CHF with reduced ejection fraction (EF 31%), the optimal treatment regimen should include an SGLT2 inhibitor, beta-blocker, and diuretic therapy, with careful management of the renin-angiotensin-aldosterone system (RAAS) inhibitors due to the elevated potassium level.

First-Line Medications

SGLT2 Inhibitors

• Start with either dapagliflozin 10 mg daily or empagliflozin 10 mg daily 1
• SGLT2 inhibitors provide mortality benefit regardless of diabetes status in patients with heart failure 1
• These medications have been shown to reduce the need for loop diuretic doses and lower rates of hyperkalemia 2

Beta-Blockers

• Continue or initiate one of the three beta-blockers proven to reduce mortality:
  • Metoprolol succinate (extended-release): 12.5-25 mg once daily, target 200 mg daily
  • Carvedilol: 3.125 mg twice daily, target 25-50 mg twice daily
  • Bisoprolol: 1.25 mg once daily, target 10 mg daily 1
• Beta-blockers should be continued unless the patient is hemodynamically unstable 1

Diuretics

• Loop diuretics (e.g., furosemide 20-40 mg once or twice daily) to manage fluid retention 2
• Adjust diuretic dose to maintain euvolemia 2
• Consider adding a thiazide diuretic if hypertension persists or for sequential nephron blockade if needed for resistant edema 2

Managing RAAS Inhibitors with Hyperkalemia

Approach to ACEi/ARB/ARNI

• With potassium of 5.3 mEq/L, RAAS inhibitors require careful management:
  • Consider starting with a lower dose of ACEi (e.g., lisinopril 2.5-5 mg daily) or ARB (e.g., valsartan 40 mg daily) 1
  • Monitor potassium levels closely (every 1-2 weeks initially) 3
  • If potassium remains stable, gradually uptitrate to target doses 1
• Sacubitril/valsartan (ARNI) is preferred over ACEi for NYHA class II-III patients with HFrEF but should be initiated after potassium is better controlled 1
  • Initial dose: 49/51 mg twice daily
  • Target dose: 97/103 mg twice daily 1

Mineralocorticoid Receptor Antagonists (MRAs)

• Defer initiation of spironolactone until potassium is better controlled (<5.0 mEq/L) 3
• When potassium is controlled, start spironolactone at 12.5-25 mg once daily 3
• Careful monitoring of potassium is essential when using MRAs 3

Monitoring and Follow-up

Laboratory Monitoring

• Check potassium and renal function:
  • Within 1 week of initiating or changing doses of RAAS inhibitors
  • Every 4 weeks for the first 12 weeks
  • Every 3 months for the first year
  • Every 6 months thereafter 3
• More frequent monitoring if:
  • eGFR <60 mL/min/1.73m²
  • Potassium >5.0 mEq/L
  • Concomitant medications that may affect potassium levels 3

Medication Adjustments

• If potassium rises to >5.5 mEq/L:
  • Reduce or temporarily discontinue RAAS inhibitors
  • Intensify diuretic therapy if volume overloaded
  • Consider patiromer for persistent hyperkalemia in patients who would benefit from RAAS inhibitors 2

Important Considerations

Medications to Avoid

• Non-steroidal anti-inflammatory drugs (NSAIDs) 1
• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) 1
• Potassium supplements and potassium-sparing diuretics (unless specifically indicated) 4

Dietary Recommendations

• Moderate sodium restriction to reduce fluid retention 1
• Consider potassium restriction if hyperkalemia persists 4
• Daily weight monitoring with action plan for weight gain >2 kg in 3 days 1

Treatment Algorithm

1. Start with: SGLT2 inhibitor + Beta-blocker + Loop diuretic
2. Add when K <5.0 mEq/L: Low-dose ACEi/ARB, then uptitrate as tolerated
3. Add when stable: MRA (spironolactone) if potassium remains <5.0 mEq/L
4. Consider: Transitioning to ARNI when stable on ACEi/ARB with controlled potassium

This approach maximizes mortality benefit while minimizing the risk of worsening hyperkalemia in a patient with heart failure and reduced ejection fraction 5.