Table 2

Considerations when managing a patient with heart failure who develops hyperkalaemia

Serum K>5.4All patients
Check for overdiuresis/hypovolaemia.
Non-selective beta-blockers can increase potassium. Review indication (prognostic benefit in HFrEF but not HFpEF) – try to continue in HFrEF.
Stop K supplements.
Stop amiloride and triamterene.
Stop non-steroidal anti-inflammatory drugs.
Stop trimethoprim.
Stop sodium substitutes.
Check for digoxin toxicity.
Provide low K diet advice.
Serum K+ Mild hyperkalaemia 5.5–5.9 mmol/LModerate hyperkalaemia 6.0–6.4 mmol/LSevere hyperkalaemia
>6.5 mmol/L
Patient clinically well, no AKIIncrease frequency of biochemical monitoring but do not stop RAAS inhibitors. Consider reducing dose.Stop RAAS inhibitor(s), repeat test
Re-start at lower dose once K+<5.5
Re-start one drug at a time, with biochemical monitoring, if the patient was previously on a combination of ACEI/ARB/ARNI plus MRA.
Admit to hospital for immediate K+-lowering treatment.
Stop RAAS inhibitor(s).
Repeat blood test 24 hours later.
Restart at lower dose once K<5.5
Restart one drug at a time, with biochemical monitoring, if the patient was previously on a combination of ACEI/ARB/ARNI plus MRA.
Patient clinically unwell with sepsis or hypovolaemia and/or AKI.Withhold RAAS inhibitors until sepsis/hypovolaemia corrected, then restart.Withhold RAAS inhibitor(s) until sepsis/hypovolaemia corrected, then restart once K<5.5.Withhold RAAS inhibitor(s) until sepsis/hypovolaemia corrected, then restart once K<5.5.
Restart one drug at a time, with biochemical monitoring, if the patient was previously on a combination of ACEI/ARB/ARNI plus MRA. 
Patient clinically unwell with decompensated heart failure with/without AKIDo not withhold RAAS inhibitors. Consider reduce dose.
Treat congestion with loop diuretics or combination of loop and thiazide diuretics.
Reduce dose of RAAS inhibitor(s) and monitor frequently.
Treat congestion with loop diuretics or combination of loop and thiazide diuretics.
Withhold RAAS inhibitor(s) and restart at lower dose when serum K<6.0.
Restart one drug at a time, with biochemical monitoring, if the patient was previously on a combination of ACEI/ARB/ARNI plus MRA.
  • ACEI, ACE inhibitor; AKI, acute kidney injury; ARB, angiotensin receptor blocker; ARNI angiotensin receptor-neprilysin inhibitor; RAAS, renin–angiotensin–aldosterone; MRA, mineralocorticoid receptor antagonist.