Guideline concordance of testing for hyperkalemia and kidney dysfunction during initiation of mineralocorticoid receptor antagonist therapy in patients with heart failure

Circ Heart Fail. 2014 Jan;7(1):43-50. doi: 10.1161/CIRCHEARTFAILURE.113.000709. Epub 2013 Nov 26.


Background: Mineralocorticoid receptor antagonists (MRA) reduce morbidity and mortality in heart failure with reduced ejection fraction but can cause hyperkalemia and acute kidney injury. Guidelines recommend measurement of serum potassium (K) and creatinine (Cr) before and serially after MRA initiation, but the extent to which this occurs is unknown.

Methods and results: Using electronic data from 3 health systems 2005 to 2008, we performed a retrospective review of laboratory monitoring among 490 patients hospitalized for heart failure with reduced ejection fraction who were subsequently initiated on MRA therapy. Median age at time of MRA initiation was 73 years, and 37.1% were women. Spironolactone accounted for 99.4% of MRA use. Initial ambulatory MRA dispensing occurred at hospital discharge in 70.0% of cases. In the 30 days before MRA initiation, 94.3% of patients had a K or Cr measurement. Preinitiation K was >5.0 mmol/L in 1.4% and Cr>2.5 mg/dL in 1.7%. In the 7 days after MRA initiation among patients who remained alive and out of the hospital, 46.5% had no evidence of K measurement; by 30 days, 13.6% remained untested. Patient factors explained a small portion of postinitiation K testing (c-statistic, 0.67).

Conclusions: Although laboratory monitoring before MRA initiation for heart failure with reduced ejection fraction is common, laboratory monitoring after MRA initiation frequently does not meet guideline recommendations, even in patients at higher risk for complications. Quality improvement efforts that encourage the use of MRA should also include mechanisms to address recommended monitoring.

Keywords: aldosterone antagonist clinical chemistry tests guideline adherence heart failure hyperkalemia mineralocorticoid receptor antagonists safety spironolactone.

Publication types

  • Multicenter Study
  • Research Support, American Recovery and Reinvestment Act
  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Acute Kidney Injury / blood
  • Acute Kidney Injury / diagnosis*
  • Acute Kidney Injury / epidemiology
  • Aged
  • Aged, 80 and over
  • Cohort Studies
  • Creatinine / blood
  • Female
  • Guideline Adherence*
  • Heart Failure / drug therapy*
  • Heart Failure / physiopathology
  • Humans
  • Hyperkalemia / blood
  • Hyperkalemia / diagnosis*
  • Hyperkalemia / epidemiology
  • Male
  • Mineralocorticoid Receptor Antagonists / adverse effects*
  • Mineralocorticoid Receptor Antagonists / therapeutic use*
  • Monitoring, Physiologic
  • Patient Selection
  • Potassium / blood
  • Retrospective Studies
  • Risk Factors
  • Stroke Volume / physiology
  • Treatment Outcome


  • Mineralocorticoid Receptor Antagonists
  • Creatinine
  • Potassium