What is the best management approach for an 87-year-old patient with acute on chronic combined systolic and diastolic heart failure and severe hyperkalemia (Basic Metabolic Panel (BMP) result of 4168 likely indicating hyperkalemia)?

Management of Severe Hyperkalemia in an Elderly Patient with Heart Failure

Immediate treatment of hyperkalemia is essential in this 87-year-old patient with acute on chronic combined systolic and diastolic heart failure, as hyperkalemia poses significant mortality risk through cardiac arrhythmias and conduction abnormalities. 1

Initial Assessment and Management

• Verify the potassium level with a repeat sample to rule out fictitious hyperkalemia from hemolysis during phlebotomy 2
• Assess for ECG changes (peaked T waves, widened QRS, prolonged PR interval, sine wave pattern) which indicate urgent treatment need 1
• Evaluate for contributing factors:
  • Medication review (ACE inhibitors, ARBs, MRAs, potassium-sparing diuretics) 1
  • Renal function (likely impaired in elderly HF patient) 1
  • Acidosis (common in acute HF decompensation) 1

Acute Hyperkalemia Management

1. Stabilize cardiac membrane if ECG changes present:

   • Administer IV calcium gluconate 10% (10 mL) over 2-3 minutes 1

2. Shift potassium intracellularly:

   • IV insulin (10 units regular) with glucose (25g) 1
   • Nebulized albuterol 10-20 mg 1

3. Eliminate potassium from the body:

   • Loop diuretics (furosemide IV) if renal function permits 1
   • Consider hemodialysis if severe hyperkalemia persists or renal function is severely impaired 1

Optimization of Heart Failure Management

• Adjust diuretic therapy:

  • Use loop diuretics at appropriate doses to maintain euvolemia while monitoring electrolytes 1
  • Consider combination diuretic therapy (loop + thiazide) for resistant fluid retention, but with careful monitoring of electrolytes 1

• Medication adjustments:

  • Temporarily hold potassium-sparing medications (MRAs, ACE inhibitors, ARBs) until potassium normalizes 1
  • Avoid NSAIDs as they can worsen hyperkalemia and sodium retention 1

• Restart GDMT with careful monitoring:

  • Once potassium is <5.0 mmol/L, cautiously reintroduce ACE inhibitors/ARBs at low doses 1
  • Monitor blood chemistry 72 hours to 1 week after restarting or adjusting doses 1

Ongoing Monitoring and Prevention

• Check serum potassium and renal function 1-2 weeks after each medication adjustment 1
• Maintain serum potassium in the 4.0-5.0 mmol/L range rather than the previously accepted 5.5 mmol/L upper limit 1
• Consider potassium binders (patiromer, sodium zirconium cyclosilicate) if hyperkalemia recurs despite optimization of other therapies 3
• Monitor magnesium levels as hypomagnesemia can contribute to electrolyte imbalances 1

Special Considerations for Elderly Patients

• Start with lower doses of medications due to altered pharmacokinetics and pharmacodynamics 1
• More frequent monitoring of renal function and electrolytes is warranted 1
• Assess for orthostatic hypotension when restarting vasodilating medications 1
• Consider comorbidities (renal dysfunction, diabetes) that increase hyperkalemia risk 1

Pitfalls to Avoid

• Don't neglect to monitor potassium levels frequently after medication adjustments 1
• Avoid excessive diuresis which can worsen renal function and lead to electrolyte abnormalities 1
• Don't permanently discontinue life-saving GDMT (ACE inhibitors, ARBs, MRAs) without attempting careful reintroduction with monitoring 1
• Be cautious with potassium supplements once hyperkalemia is resolved, as elderly HF patients can quickly shift between hypo- and hyperkalemia 2