Risk–Benefit Balance of Renin–Angiotensin–Aldosterone Inhibitor Cessation in Heart Failure Patients with Hyperkalemia

Figures

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  Figure 1. Flow diagram of patient inclusion in the study. Abbreviations: eGFR, estimated glomerular filtration rate; MRA, mineralocorticoid receptor antagonist; RAASi, renin–angiotensin–aldosterone system inhibitor.

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  Figure 2. RAASi and MRA cessation rates within 12 months of the index date. (A) RAASi cessation (n = 5059). (B) MRA cessation (n = 2220). Abbreviations: MRA, mineralocorticoid receptor antagonist; RAASi, renin–angiotensin–aldosterone system inhibitor.

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  Figure 3. RAASi treatment according to dosage category (high, medium, or low) at the index date. Percentages were calculated using the total number of prescriptions. Abbreviations: ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; MRA, mineralocorticoid receptor antagonist; RAASi, renin–angiotensin–aldosterone system inhibitor.

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  Figure 4. Cumulative incidence of clinical outcomes according to treatment cessation and non-cessation in propensity score-matched patients receiving any RAASi therapy (cumulative incidence function analysis). (A) In-hospital death; (B) emergency room visits; (C) hospitalization; (D) hospitalization due to heart failure; (E) renal replacement therapy; (F) hospitalization for MI, arrhythmia, or cardiac arrest. Abbreviations: MI, myocardial infarction; RAASi, renin–angiotensin–aldosterone system inhibitor.

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  Figure 5. Cumulative incidence of clinical outcomes according to treatment cessation and non-cessation in propensity score-matched patients receiving MRA therapy (cumulative incidence function analysis). (A) In-hospital death; (B) emergency room visit; (C) hospitalization; (D) hospitalization due to heart failure; (E) renal replacement therapy; (F) hospitalization for MI, arrhythmia, or cardiac arrest. Abbreviation: MI, myocardial infarction; MRA, mineralocorticoid receptor antagonist.

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  Figure 6. Cubic spline regression showing risk of in-hospital death as a function of serum potassium level. Data are plotted for propensity score-matched patients receiving any RAASi and for patients receiving an MRA only. The hazard ratio represents the risk of treatment cessation vs. no cessation. The dots in the figure show the point estimates of relative risks (i.e., hazard ratios of in-hospital death between patients with treatment cessation vs. no cessation) in each serum potassium value stratum. † Higher relative mortality risk of MRA cessation vs. no cessation up to serum potassium = 5.71 mmol/L. ‡ Higher relative mortality risk of RAASi cessation vs. no cessation up to serum potassium = 5.92 mmol/L. Abbreviations: MRA, mineralocorticoid receptor antagonist; RAASi, renin–angiotensin–aldosterone system inhibitor.