Heart failure (HF) is a complex, progressive illness that impacts more than 64 million individuals worldwide. It happens when the heart cannot circulate blood throughout the body as effectively as it should, due to the heart becoming weak or stiff. HF patients commonly experience recurrent deteriorations and frequent hospitalisations. Quality of life, and cardiac function, tend to worsen with each episode. Without adequate treatment, patients may progress on to advance heart failure and demise from the condition.
Heart failure rarely occurs in isolation; Chronic kidney disease (CKD) is a common co-existing condition. CKD patients are at high risk of developing hyperkalemia (high potassium levels). This is a problem because effective treatment for HF can also increase serum potassium, and may have to be stopped if potassium levels are excessive.
Dr. Chan Po Fun, consultant cardiologist from The Cardiac Centre, offers some valuable insights on managing hyperkalemia in patients with heart failure.
Doctors usually classify the type of heart failure based on the heart pumping ability. This determines the treatment strategy.
Cardiologists will use a mix of physical exams, blood tests, echocardiograms, and other imaging investigations to analyse the function of the heart, and evaluate the underlying cause of HF.
The most common modality of imaging to diagnose HF is Echocardiography. An echocardiogram uses sound waves to create detailed moving images of the heart, allowing doctors to evaluate the heart’s structure and function. It can measure ejection fraction, determine relaxation abnormalities, and detect areas of the heart that are not contracting effectively.
Other supporting tests that are performed include:
Sometimes, a cardiologist may evaluate a patient for possible blockages in the coronary arteries as a cause of HF.
The gold standard is Cardiac Catheterisation and Coronary Angiography, which involves inserting a catheter into a blood vessel and threading it to the heart. By a technique known as coronary angiography, which involves taking X-rays of the heart’s arteries, cardiologists can visualise the structure and function of the heart, measure pressures in the heart chambers, and detect blockages in the coronary arteries.
Alternatives include:
The mainstay of treatment for HFrEF is medical therapy. There are good and effective medications available, that prevent worsening of the condition.
Both the European and American Heart Failure Guidelines advocate the use of 4 main classes of medications. These are the (i) beta-blockers, (ii) angiotensin receptor/neprilysin inhibitors (ARNI) or Angiotensin-converting enzyme (ACE) inhibitors, (iii) Mineralocorticoid receptor antagonists (MRA), and (iv) Sodium-glucose cotransporter-2 (SGLT2) inhibitors.
The above should be started as soon as possible upon diagnosis, and increased to full doses rapidly, so as to maximise benefits for the HF patient.
Heart failure often coexists with other chronic conditions, such as CKD, complicating the management of the condition. Hyperkalemia, is a condition caused by elevated potassium levels in the blood. This occurs more commonly in HF patients, especially in those with co-existing CKD. It can cause dangerous heart rhythm abnormalities and sudden cardiac death if not appropriately managed.
Many essential medications used to treat HFrEF, particularly the ARNI, ACE-inhibitor, and MRA, can result in or worsen hyperkalemia. Sometimes, treatment has to be stopped because potassium reaches dangerously high levels. In these instances, the HF patients miss out on life-saving HFrEF therapy and their condition may further deteriorate.
Historically, managing hyperkalemia involved dietary restrictions. Patients are advised to eat foods that do not have as much potassium. High potassium foods should be avoided.
Sodium polystyrene sulfonate (SPS) is a traditional potassium binder that is sometimes used. However, SPS has several limitations. It causes abdominal discomfort and diarrhoea, and also interacts with other medications. This reduces its tolerability. There is also unclear if it is safe for long-term use.
There are now novel potassium binders available. These newer medications are designed to specifically target and remove excess potassium from the body without causing gastrointestinal side effects. Several clinical trials have demonstrated the efficacy and safety of these newer potassium binders.
Patients treated with these new therapies can maintain normal potassium levels without stringent dietary regulations. More importantly, their HF treatment can be resumed, and dosings can be increased to suitable levels that are effective in preventing deterioration.
Diet and Lifestyle
In HF, it is common for the body to retain water. Patients should still be mindful of their salt and fluid intake. Read nutritional labels and choose low-sodium foods. Use herbs and spices to flavor foods instead of salt. Check with your doctor regarding your fluid limit. Excessive salt or fluid consumption can result in breathlessness and leg swelling. Look out for sudden weight gain that may indicate early deterioration.
Exercising can lead to a reduced risk of HF patients being hospitalised. If you keep your body moving, you’ll help your muscles and lungs work better, which in turn puts less strain on your heart. Ideally, people with heart failure should start exercise in a supervised way. Cardiac rehabilitation class is a good way to get started.
Smoking cessation, and managing co-existing chronic conditions like diabetes and hypertension can also significantly impact overall health and heart failure outcomes.
Monitoring and Follow-up
Regular follow-ups are crucial, especially when starting or adjusting medications. While effective in managing heart failure, the medications used can also cause issues such as low blood pressure, worsening kidney function, and increased potassium levels. Reporting any side effects or symptoms immediately is important to ensure healthcare providers can provide prompt attention.
Managing HF holistically requires a nuanced approach, but with regular monitoring, lifestyle adjustments, and adherence to treatment plans, patients stand a better chance of achieving a good quality of life and heart health. Ongoing research and development into innovative therapies for HF management also show promise in preventing HF, and helping patients who already have the condition live longer and better.
Consult your healthcare professional if you require more information and practical advice on managing heart failure or its associated problems.
