Hypokalemia in Acute Coronary Syndromes and Acute Decompensated Heart Failure Joseph S. Van Tuyl, Pharm.D. PGY1 Pharmacy Resident The University of Oklahoma College of Pharmacy April 4, 2014
Disclosures No conflicts of interest. 2
Objectives 1. Describe the impact of lack of potassium replacement guidelines in patients with CVD. 2. Describe the relationship of patient characteristics on the incidence of hypokalemia in ACS and ADHF. CVD = Cardiovascular disease ACS = Acute coronary syndromes ADHF = Acute decompensated heart failure 3
Potassium Homeostasis Gennari FJ. N Engl J Med 1998; 339 (7): 451-458. 4
Causes of Hypokalemia Comorbidities Aldosteronism Cushing s syndrome Bartter syndrome Liddle syndrome Hypomagnesemia Diarrhea Vomiting Medications Diuretics Mineralocorticoids Glucocorticoids β 2 -adrenergic agonists Aminoglycosides Amphotericin B Cohn JN, et al. Arch Intern Med 2000; 160: 2429-2436. 5
Potassium Replacement Guidelines Strategies to achieve/maintain normokalemia must consider: Baseline potassium values Underlying medical conditions Medications Diet and salt intake Adherence to therapeutic regimen Lack specific recommendations and goals Cohn JN, et al. Arch Intern Med 2000; 160: 2429-2436. 6
Significance in CVD Predisposition to hypokalemia Neuroendocrine response Sympathetic nervous system Renin-angiotensin-aldosterone system Medications altering serum potassium Predisposition to arrhythmias Macdonald JE, et al. J Am Coll Cardiol 2004; 43: 155-161. 7
Potassium Goals in CVD Disorder Goal (meq/l) Reason Acute Myocardial Infarction 4.5-5.5 ventricular arrhythmias Heart Failure 4.5-5.5 ventricular arrhythmias QT and QT d Improve prognosis Macdonald JE, et al. J Am Coll Cardiol 2004; 43: 155-161. 8
Evolving Potassium Goals 70 In-Hospital Mortality According to Serum Potassium in AMI 60 50 Mortality (%) 40 30 20 10 0 <3.0 3.0-<3.5 3.5-<4.0 4.0-<4.5 4.5-<5.0 5.0-<5.5 5.5 Serum Potassium Goyal A, et al. JAMA 2012; 307(2): 157-164. 9
Implications for Patient Care Potassium homeostasis is multifactorial Current recommendations are non-specific and evolving Recommendations for potassium replacement may not reflect needs of patients with CVD Suboptimal potassium replacement Increased risk of arrhythmias Increased risk of mortality 10
Study Site OU Medical Center Presbyterian OUHSC campus Academic medical center Total 325 beds CCU 30 beds 11
Methods Retrospective, descriptive study Inclusion Criteria Admission from July 31, 2010 to July 31, 2013 18 years of age Principal admission diagnosis Unstable angina Non-ST elevation myocardial infarction ST-elevation myocardial infarction Acute decompensated heart failure Exclusion Criteria <18 years of age Cushing s/addison s disease Corticosteroid use Illicit drug use 12
Methods Primary Objective Incidence of hypokalemia (K+ <3.5 meq/l) Descriptive statistics Demographics Age Gender Ethnicity Comorbidities Charlson comorbidity index score Renal function (Cockcroft-Gault creatinine clearance) Medications 13
Methods Secondary Objective Describe the relationship of the following variables on the incidence of hypokalemia: Principal admission diagnosis Age Gender Ethnicity Renal function Charlson comorbidity index score Medications β-adrenergic antagonists, RAAS antagonists, diuretics Multiple linear regression (α = 0.05) 14
Preliminary Results 35% Incidence of Hypokalemia (K+ <3.5 meq/l) 30% 25% 20% 15% 10% 5% 0% USA NSTEMI STEMI ADHF 15
Conclusions Risk of developing hypokalemia ACS vs. ADHF Comorbidities Renal function Medications Potassium replacement protocol Individualized to patients with ACS and ADHF 16
Assessment Questions Which of the following is a consequence of hypokalemia? A. Hypotension B. Arrhythmias C. Angina D. Hypervolemia 17
Assessment Questions Which of the following predisposes patients to the development of hypokalemia? A. Cushing s syndrome B. Addison s disease C. Hypermagnesemia D. Renin-angiotensin-aldosterone antagonism 18
Acknowledgements Toni L. Ripley, Pharm.D., FCCP, BCPS (AQ-Cardiology) Holly R. Herring, Pharm.D., BCPS Jamie L. Miller, Pharm.D., BCPS Kevin Farmer, Ph.D. 19
Hypokalemia in Acute Coronary Syndromes and Acute Decompensated Heart Failure Joseph S. Van Tuyl, Pharm.D. PGY1 Pharmacy Resident The University of Oklahoma College of Pharmacy April 4, 2014