At what level of hyperkalemia should Angiotensin-Converting Enzyme (ACE) inhibitors be stopped?

From the Guidelines

ACE inhibitors should be stopped when serum potassium levels exceed 6.5 mmol/L, as recommended by the European Society of Cardiology and supported by the most recent evidence from 2021 1.

Key Considerations

• The decision to stop ACE inhibitors due to hyperkalemia should be based on the severity of hyperkalemia and the patient's underlying medical conditions, such as kidney function and presence of other potassium-sparing medications.
• According to the European Society of Cardiology guidelines, if potassium levels rise above 5.0 to 6.5 mmol/L, potassium-lowering therapy should be initiated, and the ACE inhibitor dose should be reduced or discontinued if necessary 1.
• The American College of Cardiology/American Heart Association/Heart Failure Society of America recommends using ACE inhibitors and ARBs with caution in patients with serum potassium levels above 5.0 mmol/L and considering alternative antihypertensive medications if hyperkalemia develops 1.

Management of Hyperkalemia

• When stopping an ACE inhibitor due to hyperkalemia, it is essential to monitor potassium levels until they normalize and consider alternative antihypertensive medications that do not affect potassium levels, such as calcium channel blockers or thiazide diuretics.
• The use of potassium-binding agents, such as patiromer or SZC, may allow for the continuation and optimization of RAASi therapy in patients with hyperkalemia, as suggested by the 2021 Mayo Clinic Proceedings article 1.

Clinical Context

• Hyperkalemia is a common electrolyte disorder that can develop due to increased potassium intake, reduced potassium excretion, and shift of potassium from intracellular to extracellular space, as explained in the 2018 European Heart Journal article 1.
• The severity of hyperkalemia can be classified as mild, moderate, or severe, and the risk of arrhythmic emergencies and sudden arrhythmic death varies between different patients, as discussed in the 2018 European Heart Journal article 1.

From the Research

Hyperkalemia and ACE Inhibitors

• The decision to stop ACE inhibitors due to hyperkalemia depends on various factors, including the severity of hyperkalemia and the patient's underlying medical conditions 2, 3, 4.
• According to the studies, hyperkalemia is a common complication of ACE inhibitor therapy, especially in patients with renal insufficiency or congestive heart failure 2, 3, 4.
• The risk of hyperkalemia is higher in patients with chronic kidney disease, and the incidence of hyperkalemia can be as high as 10% in patients taking ACE inhibitors 3, 5.

Potassium Levels and ACE Inhibitor Therapy

• The studies suggest that ACE inhibitors should be stopped or adjusted when potassium levels exceed 6.0 mmol/L, as this is considered severe hyperkalemia 2, 5.
• However, the exact potassium level at which to stop ACE inhibitors is not universally agreed upon and may depend on individual patient factors, such as renal function and comorbidities 3, 4.
• Regular monitoring of potassium levels is essential in patients taking ACE inhibitors, especially in those with chronic kidney disease or other risk factors for hyperkalemia 3, 4, 5.

Comparison of ACE Inhibitors and Angiotensin Receptor Blockers

• Some studies suggest that angiotensin receptor blockers (ARBs) may be associated with a lower risk of hyperkalemia compared to ACE inhibitors, especially in patients with chronic kidney disease 6.
• However, other studies have found similar rates of hyperkalemia between ACE inhibitors and ARBs 5.
• The choice between ACE inhibitors and ARBs should be based on individual patient factors and clinical judgment, taking into account the potential risks and benefits of each medication 3, 4, 6.