NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update

Hyperkalaemia in HF: Primary Care Management

Key messages

  • Eplerenone and spironolactone are mineralocorticoid receptor antagonists (MRAs)
  • Combining ACEI (or ARB) with MRA in patients with HF due to reduced LVEF improves major outcomes
  • Clinically relevant hyperkalaemia is relatively common in this cohort
  • Appropriate monitoring of K+ and renal function is essential to reduce the risk of hyperkalaemia
  • The NHSGGC local enhanced service (LES) provides advice on the frequency of monitoring
  • Advice from specialist HF teams should be sought when managing hyperkalaemia in primary care


The MRAs eplerenone and spironolactone improve morbidity and mortality in patients with HF. They reduce the relative risk of all-cause mortality by 15% to 30%. Patients hospitalised with HF in the UK who survive to discharge, have an annual mortality of approximately 30%. Such outcomes are worse than most common cancers.

MRAs are known to cause more clinically relevant hyperkalaemia in the ‘real world’ than in trials. This is often attributable to poor compliance with monitoring requirements. MRAs, ACEIs, ARBs and even beta-blockers are known to increase serum potassium. The survival benefit of MRAs in HF is not eliminated by the presence of hyperkalaemia and a balanced approach to managing hyperkalaemia is required.

New national guidance on changes in potassium and renal function during ACEI, ARB, diuretic and MRA treatment in primary care has been published by Think Kidneys, The Renal Association and The British Society for Heart Failure. It outlines the principles for interpreting potassium results and provides clear advice on how to manage episodes of mild (K+ 5.5-5.9mmol/L), moderate (K+ 6.0–6.4mmol/L) and severe (K+ ≥6.5mmol/L) hyperkalaemia. Advice should be sought from local HF specialist teams to help with decision making.


Published 24/01/18