150 A UK survey of the perceptions of healthcare professionals around hyperkalaemia and the prescription of RAAS inhibitors

Introduction Renin-angiotensin-aldosterone-system inhibitors (RAASi) are commonly used for a number of indications, including in the management of hypertension, proteinuric chronic kidney disease (CKD), post myocardial infarction and heart failure with reduced ejection fraction (HFrEF). Their use is often hindered by hyperkalaemia leading to underutilisation and/or underdosing. Purpose Assess perceptions of primary and secondary healthcare professionals regarding benefits of RAASi according to indication and in the context of developing hyperkalaemia, to identify barriers to optimal utilisation, and to explore options for improving management protocols, specifically in HFrEF. Methods An online survey was distributed in primary and secondary healthcare settings in Hampshire, UK, to evaluate: (i) understanding of benefit of the drugs according to indication, (ii) prescription of RAASi at various levels of potassium (K+) in patients with hypertension or HFrEF, (iii) educational needs. Hyperkalaemia was divided into mild (serum K+ 5.5 - 5.9 mmol/L), moderate (serum K+ 6.0 - 6.4 mmol/L), and severe (serum K+ ≥ 6.5 mmol/L). Results From November 2021 to January 2023, 300 questionnaires were completed by 274 (91%) doctors (123 juniors, 56 registrars, 54 consultants and 41 general practitioners), 22 (7%) non-medical prescribers, and 4 (1%) pharmacists. 80% were working in secondary care across a broad range of specialities (small numbers in cardiology n=31 and nephrology n=15). Whilst the majority of respondents were aware of prognostic benefit of angiotensin converting enzyme inhibitors (ACEi) for patients with HFrEF, 38% were unaware of symptom benefit. In contrast, 80% of respondents thought mineralocorticoid receptor antagonists (MRA) could improve symptoms for patients with HFrEF, but 26% were unaware of potential benefits on reducing heart failure hospitalisation and 35% unaware of mortality benefit. Figure 1 shows response to RAASI prescription according to different levels of hyperkalaemia. There were small differences in the willingness to continue ACEi (at same or reduced dose) according to indication in favour of HFrEF as compared to hypertension and MRA. When considering a clinical scenario for a patient with HFrEF whose ACEi treatment was interrupted due to hyperkalaemia (K+ 5.9 mmol/L), 77% of respondents would consider re-commencing the ACEi if the potassium levels < 5.5 mmol/L and only 1% would consider resuming therapy in the context of moderate or severe hyperkalaemia (Fig 2). Whilst 74% of the healthcare professionals were familiar with their local hyperkalaemia management protocol, the vast majority (93%) supported the need for dedicated training on RAASi dose adjustment and hyperkalaemia management. Conclusion This survey, across a broad range of health care professionals, shows uncertainties around knowledge of benefits of RAASi in patients with HFrEF and there is sizeable variation in the prescribing response to degrees of hyperkalaemia. Given the voluntary nature of the survey, it is plausible that these data are biased towards individuals with greater understanding. Regardless, there is a need for continued education with a goal of improving patient-centred care. Conflict of Interest Non