Serum potassium dynamics during acute heart failure hospitalization



Available information about prognostic implications of potassium levels alteration in the setting of acute heart failure (AHF) is scarce.


We aim to describe the prevalence of dyskalemia (hypo or hyperkalemia), its dynamic changes during AHF-hospitalization, and its long-term clinical impact after hospitalization.


We analyzed 1779 patients hospitalized with AHF who were included in the REDINSCOR II registry. Patients were classified in three groups, according to potassium levels both on admission and discharge: hypokalemia (potassium < 3.5 mEq/L), normokalemia (potassium = 3.5–5.0 mEq/L and, hyperkalemia (potassium > 5 mEq/L).


The prevalence of hypokalemia and hyperkalemia on admission was 8.2 and 4.6%, respectively, and 6.4 and 2.7% at discharge. Hyperkalemia on admission was associated with higher in-hospital mortality (OR = 2.32 [95% CI: 1.04–5.21] p = 0.045). Among patients with hypokalemia on admission, 79% had normalized potassium levels at discharge. In the case of patients with hyperkalemia on admission, 89% normalized kalemia before discharge. In multivariate Cox regression, dyskalemia was associated with higher 12-month mortality, (HR = 1.48 [95% CI, 1.12–1.96], p = 0.005). Among all patterns of dyskalemia persistent hypokalemia (HR = 3.17 [95% CI: 1.71–5.88]; p < 0.001), and transient hyperkalemia (HR = 1.75 [95% CI: 1.07–2.86]; p = 0.023) were related to reduced 12-month survival.


Potassium levels alterations are frequent and show a dynamic behavior during AHF admission. Hyperkalemia on admission is an independent predictor of higher in-hospital mortality. Furthermore, persistent hypokalemia and transient hyperkalemia on admission are independent predictors of 12-month mortality.

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Angiotensin-converting enzyme


Acute heart failure


Angiotensin II receptor blocker


Heart failure


Mineralocorticoid receptor antagonist


Renin–angiotensin–aldosterone system


  1. 1.

    Sayago-Silva I, García-López F, Segovia-Cubero J (2013) Epidemiología de la insuficiencia cardiaca en España en los últimos 20 años. Rev Española Cardiol 66:649–656.

    Article  Google Scholar 

  2. 2.

    Mentz RJ, O’Connor CM (2016) Pathophysiology and clinical evaluation of acute heart failure. Nat Rev Cardiol 13:28–35.

    CAS  Article  Google Scholar 

  3. 3.

    Ponikowski P, Voors AA, Anker SD et al (2016) 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 37:2129–2200m.

    Article  PubMed  Google Scholar 

  4. 4.

    Urso C, Brucculeri S, Caimi G (2015) Acid–base and electrolyte abnormalities in heart failure: pathophysiology and implications. Heart Fail Rev 20:493–503.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Komajda M, Anker SD, Cowie MR et al (2016) Physicians’ adherence to guideline-recommended medications in heart failure with reduced ejection fraction: data from the QUALIFY global survey. Eur J Heart Fail 18:514–522.

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Núñez J, Bayés-Genís A, Zannad F et al (2018) Long-term potassium monitoring and dynamics in heart failure and risk of mortality. Circulation 137:1320–1330.

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Khan SS, Campia U, Chioncel O et al (2015) Changes in serum potassium levels during hospitalization in patients with worsening heart failure and reduced ejection fraction (from the EVEREST trial). Am J Cardiol 115:790–796.

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Salah K, Pinto YM, Eurlings LW et al (2015) Serum potassium decline during hospitalization for acute decompensated heart failure is a predictor of 6-month mortality, independent of N-terminal pro-B-type natriuretic peptide levels: an individual patient data analysis. Am Heart J 170:531-542.e1.

    CAS  Article  PubMed  Google Scholar 

  9. 9.

    Formiga F, Chivite D, Corbella X et al (2019) Influence of potassium levels on one-year outcomes in elderly patients with acute heart failure. Eur J Intern Med 60:24–30.

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Haukoos JS, Newgard CD (2007) Advanced statistics: missing data in clinical research—part 1: an introduction and conceptual framework. Acad Emerg Med 14:662–668.

    Article  PubMed  Google Scholar 

  11. 11.

    Newgard CD, Haukoos JS (2007) Advanced statistics: missing data in clinical research—part 2: multiple imputation. Acad Emerg Med 14:669–678.

    Article  PubMed  Google Scholar 

  12. 12.

    Hoss S, Elizur Y, Luria D et al (2016) Serum potassium levels and outcome in patients with chronic heart failure. Am J Cardiol 118:1868–1874.

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Davidsen L, Aldahl M, Krogager ML et al (2017) Associations of serum potassium levels with mortality in chronic heart failure patients. Eur Heart J 38:2890–2896.

    CAS  Article  PubMed  Google Scholar 

  14. 14.

    Crespo-Leiro MG, Barge-Caballero E, Segovia-Cubero J et al (2019) Hyperkalemia in heart failure patients in Spain and its impact on guideline- directed medical therapy. Rev Esp Cardiol.

    Article  PubMed  Google Scholar 

  15. 15.

    Tromp J, ter Maaten JM, Damman K et al (2017) Serum potassium levels and outcome in acute heart failure (data from the PROTECT and COACH trials). Am J Cardiol 119:290–296.

    CAS  Article  PubMed  Google Scholar 

  16. 16.

    Legrand M, Ludes PO, Massy Z et al (2018) Association between hypo- and hyperkalemia and outcome in acute heart failure patients: the role of medications. Clin Res Cardiol 107:214–221.

    CAS  Article  PubMed  Google Scholar 

  17. 17.

    Bielecka-Dabrowa A, Mikhailidis DP, Jones L et al (2012) The meaning of hypokalemia in heart failure. Int J Cardiol 158:12–17.

    Article  PubMed  Google Scholar 

  18. 18.

    Ferreira JP, Butler J, Rossignol P et al (2020) Abnormalities of potassium in heart failure: JACC state-of-the-art review. J Am Coll Cardiol 75:2836–2850.

    CAS  Article  PubMed  Google Scholar 

  19. 19.

    Girerd N, Pang PS, Swedberg K et al (2013) Serum aldosterone is associated with mortality and re-hospitalization in patients with reduced ejection fraction hospitalized for acute heart failure: analysis from the EVEREST trial. Eur J Heart Fail 15:1228–1235.

    CAS  Article  PubMed  Google Scholar 

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This work is funded by the Instituto de Salud Carlos III (Ministry of Economy, Industry, and Competitiveness) and co-funded by the European Regional Development Fund, through the CIBER in cardiovascular diseases (CB16/11/00502).

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Correspondence to Juan F. Delgado.

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Caravaca Perez, P., González-Juanatey, J.R., Nuche, J. et al. Serum potassium dynamics during acute heart failure hospitalization. Clin Res Cardiol (2020).

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  • Dyskalemia
  • Hyperkalemia
  • Hypokalemia
  • Potassium
  • Heart failure