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Original article
Prognostic implications of hypo and hyperkalaemia in acute heart failure with reduced ejection fraction. Analysis of cardiovascular mortality and hospital readmissions
Implicaciones pronósticas de la hipo e hiperpotasemia en la insuficiencia cardíaca aguda con fracción de eyección reducida. Análisis de la mortalidad cardiovascular y reingresos hospitalarios
Rocío del Pilar Laymito-Quispea,b,
Corresponding author
chiolaymito@yahoo.es

Corresponding author.
, Raquel López-Vilellaa,b, Ignacio Sánchez-Lázaroa,b,c, Víctor Donoso-Trenadoa,b, Silvia Lozano-Edoa,b, Luis Martínez-Dolzb,d, Luis Almenar-Boneta,b,c,d
a Unidad de Insuficiencia Cardíaca y Trasplante, Hospital Universitari i Politècnic La Fe, Valencia, Spain
b Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, Valencia, Spain
c Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Valencia, Spain
d Facultad de Medicina, Universidad de Valencia, Valencia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; is a complex and highly prevalent clinical syndrome that causes high morbidity and mortality rates worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The progressive nature of the condition results in frequent decompensations and hospital readmissions during its course&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> These events significantly worsen not only the health-related quality of life of these patients&#44; but also their prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Each decompensated HF event is accompanied by significant alterations in the internal milieu&#44; closely related to ionic balance&#44; especially potassium &#40;K<span class="elsevierStyleSup">&#43;</span>&#41;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#59; these disorders are caused by the disease itself&#44; development of cardiorenal syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> drugs used to improve symptoms and disease prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">There are studies that show that the level of K<span class="elsevierStyleSup">&#43;</span> at the time of hospital discharge is a medium-long term prognostic marker associated with higher mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> It is also one of the most common factors limiting the titration of optimal medical therapy for HF&#44; often leading to underuse of disease-modifying drugs&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Therefore&#44; close monitoring of serum potassium levels is not only necessary in the follow-up of these patients&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> but also on admission&#44; as this serum value expresses the patient&#8217;s usual day-to-day condition&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The hypothesis of this study was that potassium abnormalities &#40;hyperkalaemia or hypokalaemia&#41; in the first blood test on admission for decompensated HF would have negative prognostic implications for morbidity and mortality &#40;readmission for decompensation and cardiovascular death&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Thus&#44; the aim of this study was to analyse whether abnormalities above or below the normal range in serum potassium levels on admission are associated with a higher probability of hospital readmission and&#47;or higher mortality in patients with a diagnosis of HF and reduced left ventricular ejection fraction who are admitted to hospital for acute decompensation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and method</span><p id="par0025" class="elsevierStylePara elsevierViewall">Observational&#44; retrospective cross-sectional study&#46; A total of 1&#44;397 patients admitted to the Cardiology Department with a diagnosis of acute HF were retrospectively selected from 1 January 2016 to 30 June 2020&#46; In order to homogenize the sample&#44; only patients with left ventricular ejection fraction &#40;LVEF&#41;&#8239;<span class="elsevierStyleUnderline">&#60;</span>&#8239;40&#37; were selected&#46; Patients under 18 years of age&#44; transferred from other hospitals&#44; scheduled admissions for studies or therapeutic procedures&#44; treatments with cation exchange resins and renal replacement therapy &#40;haemodialysis&#47;peritoneal dialysis&#44; ultrafiltration&#41; were excluded&#46; The number of patients included was 689 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; All patients were included sequentially and prospectively on the same day of admission in a database by the same person&#46; In all cases a haematological&#44; renal and electrolyte profile was obtained immediately on arrival at the emergency department&#46; The patients were grouped according to the levels of potassium on admission&#44; in such a way that 3 groups were considered&#58; hypokalaemia &#40;K<span class="elsevierStyleSup">&#43;</span>&#8239;&#60;&#8239;3&#46;5&#8239;mmol&#47;l&#41;&#44; normokalaemia &#40;K<span class="elsevierStyleSup">&#43;</span>&#8239;&#61;&#8239;3&#46;5&#8211;5&#46;0&#8239;mmol&#47;l&#41; and hyperkalaemia &#40;K<span class="elsevierStyleSup">&#43;</span>&#8239;&#62;&#8239;5&#46;0&#8239;mmol&#47;l&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The baseline characteristics of the patients were analysed&#44; as well as their medical history&#44; drugs used when they went to the hospital emergency department for decompensation and the first blood test performed on admission&#46; The primary endpoint was mortality and hospital readmission between the study groups at 365 days&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The Ethics Committee of the site approved the study&#46; The research complied with the ethical principles applicable to human subjects as set out in the Declaration of Helsinki&#46; Variables are expressed as percentages&#44; mean and standard deviation&#46; Univariate comparison was performed using Pearson&#8217;s chi-square test&#44; Student&#39;s t-test and analysis of variance&#46; Cox regression analysis &#40;survival&#41; and binary logistic regression &#40;readmissions&#41; were used for the multivariate comparison&#44; introducing the variables death and readmission as dependent variables&#46; The independent variables included were those that had a significance greater than 0&#46;05 in the univariate analysis&#44; entered using the &#8220;intro&#8221; method&#46; A value of p&#8239;&#60;&#8239;0&#46;05 was considered significant&#46; The statistical analysis was carried out with IBM SPSS Statistics version 27 software&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Demographic characteristics and clinical profile of the study patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">The study group was predominantly male&#44; in NYHA functional class II&#8211;III&#44; mostly hypertensive&#44; dyslipidaemic and diabetic with reduced LVEF &#40;&#60;33&#37;&#41;&#46; Ischemic heart disease was the most common&#44; especially in the hyperkalaemia group &#40;45&#37;&#41;&#59; other aetiologies such as tachycardiomyopathy were significant&#44; especially in the hypokalaemia group&#46; A high percentage were receiving disease-modifying drug therapy&#44; angiotensin-converting enzyme inhibitors&#47;angiotensin II receptor blockers &#40;ACEIs&#47;ARBs&#41; in both hypo and hyperkalaemia&#46; The percentage of dual angiotensin receptor-neprilysin inhibitor &#40;ARNi&#41; was lower in the hypokalaemia group&#46; More than 70&#37; were receiving mineralocorticoid receptor antagonists &#40;MRAs&#41; on admission&#46; Beta-blocker &#40;BBs&#41; therapy exceeded 80&#37; in the groups studied and more than 90&#37; were prescribed loop diuretics on admission&#46; Analysing the study groups&#44; significant differences were observed&#44; especially in terms of age&#59; hypokalaemia occurred in relatively younger patients compared to the other 2 groups studied&#46; The laboratory values at admission were significant&#46; In all other respects&#44; the groups were similar to each other&#46; The clinical characteristics of the patients included in the analysis are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Survival and readmission analysis</span><p id="par0045" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the relationship between potassium levels on admission and cumulative survival at 3&#46;5 years&#46; There were differences between the study groups&#44; in particular between patients with normokalaemia and the other 2&#46; Survival curves begin to diverge from the baseline&#46; The probability of survival at one year was also different between the groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Significant differences were found between patients with hypokalaemia and hyperkalaemia in terms of mean survival time and mortality rate&#44; with HF-related mortality being prevalent in the 3 groups studied&#46; No statistically significant differences were found in the hospital readmission rate &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The probability of survival free of readmission event is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; with no differences found between the study groups&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Multivariate analysis</span><p id="par0050" class="elsevierStylePara elsevierViewall">A multivariate analysis was performed to find out the relationship between potassium alterations with mortality and readmissions as the primary objectives of the study&#46; Significant variables in the univariate analysis were included in this analysis&#58; age&#44; dyslipidaemia&#44; ARNi treatment&#44; MRAs treatment and all laboratory parameters on admission&#46; Hypokalaemia increased the risk of death 2&#46;4-fold &#40;p&#8239;&#60;&#8239;0&#46;007&#41; and hyperkalaemia 1&#46;9-fold &#40;at the limit of significance&#44; p&#8239;&#60;&#8239;0&#46;055&#41;&#46; Likewise&#44; elevated serum creatine level and age were variables associated with mortality&#44; both in the hyperkalaemia and hypokalaemia cohorts&#46; Readmissions were not significantly associated with any of these electrolyte abnormalities &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Potassium changes &#40;hypokalaemia or hyperkalaemia&#41; at the time of hospital discharge after admission for decompensated HF are a major clinical problem that has been associated with mortality and readmissions&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a> However&#44; studies on the prediction of morbidity and mortality in relation to the first blood test recorded in hospital emergency care are scarce&#44; although it is the value that expresses the usual clinical condition of the patient&#46; Therefore&#44; this study aimed to assess the prognostic implications of potassium disorders on hospital admission in terms of mortality and readmission in patients with acute HF and reduced LVEF&#44; finding that both hypokalaemia and hyperkalaemia worsen the prognosis of the disease by significantly increasing mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> However&#44; in the present study it has been confirmed that dyskalemia is not independently associated with the readmission rate when compared with patients in the normal range&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">In this cohort of patients with acute HF with reduced LVEF&#44; the mean K<span class="elsevierStyleSup">&#43;</span> on admission was 4&#46;3&#8239;<span class="elsevierStyleUnderline">&#43;</span>&#8239;0&#46;5&#8239;mmol&#47;l&#59; 3&#46;2&#8239;<span class="elsevierStyleUnderline">&#43;</span>&#8239;0&#46;2&#8239;mmol&#47;l for hypokalaemia and 5&#46;9&#8239;<span class="elsevierStyleUnderline">&#43;</span>&#8239;0&#46;5&#8239;mmol&#47;l in the hyperkalaemia group&#44; which was more prevalent in the population over the age of 70&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Our analysis showed a significant association between patients over 75 years of age with more impaired renal function and higher creatinine levels for developing hyperkalaemia&#44; a clinical profile very similar to that described in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15&#44;16</span></a> In a recent study<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> with multivariable analysis models&#44; adjusted for potential confounding variables related to adverse events in patients with acute HF&#44; hyperkalaemia measured during admission of patients with acute decompensated HF was associated with increased mortality rate at 90 days with a HR 1&#44; 03&#44; 95&#37; CI 1&#46;02&#8211;1&#46;04 and p&#8239;&#60;&#8239;0&#46;05&#44; for changes of 0&#46;1&#8239;mmol&#47;l serum K<span class="elsevierStyleSup">&#43;</span> above 4&#44; 5&#8239;mmol&#47;l&#44; even more so if the glomerular filtration rate was&#8239;&#60;&#8239;60&#8239;ml&#47;min&#46; Tromp et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> reported a positive univariate association between potassium levels on admission and 180-day all-cause mortality&#44; although this association was lost when corrected for renal function in the multivariate analysis&#44; suggesting that potassium levels on admission for acute HF reflect clinical associations and do not have an independent effect on mortality&#46; Our study contrasts with these results&#46; The 1-year mortality rate for hyperkalaemia measured at patient admission was 40&#46;8&#37; with HR 1&#46;9 &#40;95&#37; CI&#58; 0&#46;98&#8722;3&#46;51&#59; p&#8239;&#60;&#8239;0&#46;055&#41; at the upper limit of significance&#44; but with higher K<span class="elsevierStyleSup">&#43;</span> values of 5&#46;9&#8239;<span class="elsevierStyleUnderline">&#43;</span>&#8239;0&#46;5&#8239;mmol&#47;l&#46; Regarding the association with renal function&#44; creatinine levels of 2&#46;1&#8239;<span class="elsevierStyleUnderline">&#43;</span>&#8239;1&#46;1&#8239;mg&#47;dl were statistically significant with an HR of 1&#46;3 &#40;95&#37; CI&#58; 1&#46;1&#8722;1&#46;7&#59; p&#8239;&#60;&#8239;0&#46;012&#41; for 1-year mortality regarding hyperkalaemia compared with patients with K<span class="elsevierStyleSup">&#43;</span> in normal range&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In a context of systemic congestion with a haemodynamic pattern of decompensated HF and more advanced stages of disease&#44; high doses of loop diuretics and even combinations of diuretics with different sites of action<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> are required to produce a sequential nephron blockade&#44; resulting in an intense kaliuretic effect&#46; This fact&#44; together with the activation of the renin angiotensin aldosterone system due to the decrease in circulating volume is a risk factor for the development of hypokalaemia&#46; In the work of Caravaca et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> serum potassium levels&#8239;&#60;&#8239;4&#8239;mmol&#47;l measured on admission for acute decompensated HF were significantly associated with in-hospital mortality&#44; but not with long-term mortality&#44; while levels of K<span class="elsevierStyleSup">&#43;</span>&#8239;&#60;&#8239;3&#46;5&#8239;mmol&#47;l on admission did not show to be related to higher hospital mortality&#46; In another cross-continental&#44; observational<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> study of patients hospitalised for acute HF&#44; hypokalaemia &#40;K<span class="elsevierStyleSup">&#43;</span>&#8239;&#60;&#8239;3&#46;5&#8239;mmol&#47;l&#41; on admission increased 90-day mortality 1&#46;2-fold compared with normokalaemia &#40;HR 1&#46;22&#59; 95&#37; CI&#58; 1&#46;06&#8211;1&#46;40&#41;&#44; although in the confounder-adjusted analysis they found no association between hypokalaemia and mortality for changes of 0&#46;1&#8239;mmol&#47;l K<span class="elsevierStyleSup">&#43;</span> below 3&#46;5&#8239;mmol&#47;l &#40;HR&#58; 1&#46;03&#59; 95&#37; CI&#58; 0&#46;98&#8211;1&#46;09&#41;&#44; our findings differ from those previously reported&#46; The one year mortality rate for a K<span class="elsevierStyleSup">&#43;</span>&#8239;&#60;&#8239;of 3&#46;5&#8239;mmol&#47;l in the multivariate analysis of our cohort was 37&#46;8&#37;&#44; doubling the risk of dying &#40;HR 2&#46;4&#59; 95&#37; CI&#58; 1&#44;3-4&#44;7&#59; p&#8239;&#60;&#8239;0&#44;007&#41;&#59; this could be explained by more severe acute HF conditions or more advanced stages of disease with systemic congestion prevalence and the need for higher doses of diuretics combined with higher urinary potassium loss&#44; as well as a relatively younger population with hypokalaemia &#40;67&#46;8&#8239;<span class="elsevierStyleUnderline">&#43;</span>&#8239;13&#46;6 years&#41;&#46; This study found a statistically significant association between age and hypokalaemia &#40;p&#8239;&#60;&#8239;0&#46;02&#41;&#46; Creatinine levels of 1&#46;2&#8239;<span class="elsevierStyleUnderline">&#43;</span>&#8239;0&#46;6&#8239;mg&#47;dl also reached statistical significance&#44; increasing the risk of dying 1&#46;4-fold in the hypokalaemia group &#40;HR&#58; 1&#46;4&#44; 95&#37; CI&#58; 1&#46;1&#8722;1&#46;8&#44; p&#8239;&#60;&#8239;0&#46;005&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The benefits of disease-modifying drug therapy in slowing HF progression&#44; improving quality of life&#44; reducing symptoms and hospital readmissions are well known<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>&#59; therefore&#44; it is important to maintain and&#47;or restart it after a decompensation&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> However&#44; this therapy could alter serum potassium levels&#44; favouring or inhibiting its excretion&#59; especially if associated with renal dysfunction&#44; ACEIs increase K<span class="elsevierStyleSup">&#43;</span> levels between 10&#37; and 38&#37; in hospitalized patients&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a> ARNi<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> in 15&#37;&#59; the RALES trial<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> found a significant increase in K<span class="elsevierStyleSup">&#43;</span> levels compared to placebo &#40;4&#46;54&#8239;&#177;0&#46;49 vs&#46; 4&#46;28&#8239;&#177;&#8239;0&#46;50&#8239;mmol&#47;l&#59; p&#8239;&#60;&#8239;0&#46;001&#41; after the first month of treatment with MRAs&#46; It is interesting to note that in our study&#44; 92&#37; of the patients were taking ACEIs&#47;ARBs or ARNi upon admission&#44; 71&#37; MRAs and 87&#37; BBs&#59; these drug titration levels are much higher than those reported in previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a> Despite this&#44; we found a lower incidence of hyperkalaemia &#40;7&#46;1&#37;&#41; and hypokalaemia &#40;6&#46;5&#37;&#41; respectively&#44; although we do not know the percentage of optimal dose titrated for each drug&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Differences were found in the readmission rate between patients with hypokalaemia &#40;22&#46;2&#37;&#41;&#44; hyperkalaemia &#40;44&#46;9&#37;&#41; and normokalaemia &#40;36&#46;14&#37;&#41;&#46; The comparative analysis between them showed that patients with hypokalaemia on admission due to a decompensated HF event had lower readmission rates&#44; although it did not reach statistical significance &#40;p&#8239;&#60;&#8239;0&#46;06&#41; versus those with normal potassium&#46; A recent study<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> evaluating older adult patients admitted for acute HF with hypokalaemia &#60;4 or 3&#46;5&#8239;mmol&#47;l on admission showed no significant association with HF readmissions&#46; We should bear in mind that hypokalaemia identified in daily clinical practice hospitalisation tends to be corrected to normal ranges&#59; this may reduce its impact on challenging endpoints&#46; On the other hand&#44; our study showed a trend for hyperkalaemia to be associated with more hospital readmissions at one year compared to potassium levels in the normal range&#44; although this did not reach statistical significance &#40;p&#8239;&#60;&#8239;0&#46;2&#41;&#46; These findings do not differ from those reported in previous studies&#46; The ESC-EORP-HFA Heart Failure Long-Term Registry<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> found no statistical association &#40;p&#8239;&#60;&#8239;0&#46;565&#41; in terms of readmissions for HF and baseline hyperkalaemia vs&#46; normokalaemia&#44; but contrasts with other studies<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> where 1-year readmissions increased 1&#46;6-fold in patients with K<span class="elsevierStyleSup">&#43;</span>&#8239;&#62;&#8239;5&#46;5&#8239;mmol&#47;l compared to patients with normokalaemia on admission &#40;p&#8239;&#60;&#8239;0&#46;007&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Our study has limitations as it is a retrospective observational study with a small number of cases&#46; However&#44; the number of patients included and the length of follow-up&#44; together with the use of the same management guidelines&#44; make the sample homogeneous and reflect real clinical practice in a reference HF centre&#46; Furthermore&#44; although there are prognostic studies that analyse the potassium value at discharge in patients admitted for decompensated HF&#44; prognostic analyses of morbidity and mortality on admission potassium value in these patients are scarce&#46; Moreover&#44; all data have been collected comprehensively and prospectively by a cardiology specialist&#44; which makes the results more robust&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion&#44; both hyperkalaemia and hypokalaemia on admission for decompensated HF result in a negative prognostic impact on the survival of these patients&#46; Other factors independently associated with mortality are creatinine and age&#46; On the other hand&#44; the effect on the probability of hospital readmission at one year is not demonstrated in this study&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interests</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objectives</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Potassium alterations constitute a major clinical problem in decompensated heart failure &#40;HF&#41;&#46; This study aims to assess the prognostic implications of hypo and hyperkalaemia on admission for acute HF in cardiovascular mortality and hospital readmissions&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">From January 2016 to June 2020&#44; 1&#44;397 cases with a diagnosis of acute HF were admitted&#46; Admission programmed for study&#44; elective therapies&#44; and patients with LVEF &#62;40&#37; were excluded&#46; The study was carried out on 689 patients&#44; 45 with K<span class="elsevierStyleSup">&#43;</span> &#60;3&#46;5&#8239;mmol&#47;l&#44; 49&#8239;K<span class="elsevierStyleSup">&#43;</span> &#62;5&#46;0&#8239;mmol&#47;l and 595&#8239;K<span class="elsevierStyleSup">&#43;</span> 3&#46;5&#8211;5&#46;0&#8239;mmol&#47;l&#46; Medical history&#44; baseline clinical profile&#44; drug therapy&#44; and potassium levels obtained upon admission were analysed&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Annual mortality due to hypokalaemia &#40;K<span class="elsevierStyleSup">&#43;</span> &#60;3&#46;5&#8239;mmol&#47;l&#41; was 37&#46;8&#37; &#40;HR 2&#46;4&#58; 95&#37;CI 1&#46;3&#8722;4&#46;7&#59; p&#8239;&#60;&#8239;0&#46;007&#41;&#59; for hyperkalaemia 40&#46;8&#37; &#40;HR 1&#46;9&#58; 95&#37; CI&#58; 0&#46;98&#8722;3&#46;51&#59; p&#8239;&#60;&#8239;0&#46;055&#41;&#46; Creatinine level and age were variables associated with mortality in both the hyperkalaemic and hypokalaemic cohorts&#46; Hospital readmissions did not show statistical association with these electrolyte disorders&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">In patients admitted for decompensated HF&#44; both hyperkalaemia and hypokalaemia determined at admission have a negative prognostic impact on survival&#46; Creatinine and age are other independent factors associated with mortality&#46; The effect on the probability of hospital readmission at one year is not demonstrated in this study&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Background and objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes y objetivos</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Las alteraciones del potasio constituyen un problema cl&#237;nico de gran magnitud en la insuficiencia card&#237;aca &#40;IC&#41; descompensada&#46; Este estudio pretende valorar las implicaciones pron&#243;sticas de la hipo e hiperpotasemia al ingreso por IC aguda en la mortalidad cardiovascular y reingresos hospitalarios&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">De enero del 2016 a junio del 2020 fueron ingresados 1&#46;397 casos con diagn&#243;stico de IC aguda&#46; Se excluyeron ingresos programados para estudio&#44; terapias electivas y pacientes con fracci&#243;n de eyecci&#243;n del ventr&#237;culo izquierdo &#40;FEVI&#41; <span class="elsevierStyleUnderline">&#62;</span>40&#37;&#46; El estudio se realiz&#243; sobre 689 pacientes&#44; 45 con potasio &#40;K<span class="elsevierStyleSup">&#43;</span>&#41; &#60;3&#44;5&#8239;mmol&#47;l&#44; 49&#8239;K<span class="elsevierStyleSup">&#43;</span> &#62;5&#44;0&#8239;mmol&#47;l y 595&#8239;K<span class="elsevierStyleSup">&#43;</span> 3&#44;5&#8722;5&#44;0&#8239;mmol&#47;l&#46; Se analizaron los antecedentes&#44; perfil cl&#237;nico basal&#44; terapia farmacol&#243;gica y niveles de potasio obtenidos al ingreso&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">La mortalidad anual por hipopotasemia &#40;K<span class="elsevierStyleSup">&#43;</span>&#8239;&#60;&#8239;de 3&#44;5&#8239;mmol&#47;l&#41; fue 37&#44;8&#37; &#40;HR 2&#44;4&#58; IC95&#37; 1&#44;3&#8211;4&#44;7&#59; p&#8239;&#60;&#8239;0&#44;007&#41;&#59; para hiperpotasemia de 40&#44;8&#37; &#40;HR 1&#44;9&#58; IC95&#37;&#58; 0&#44;98&#8722;3&#44;51&#59; p&#8239;&#60;&#8239;0&#44;055&#41;&#46; El nivel de creatinina y la edad fueron variables asociadas a mortalidad&#44; tanto en la cohorte de hiperpotasemia como en la de hipopotasemia&#46; Los reingresos hospitalarios no mostraron asociaci&#243;n estad&#237;stica con estos trastornos electrol&#237;ticos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">En los pacientes ingresados por IC descompensada&#44; tanto la hiperpotasemia como la hipopotasemia determinadas al ingreso&#44; tienen impacto pron&#243;stico negativo en la supervivencia&#46; La creatinina y la edad son otros factores independientes asociados a mortalidad&#46; El efecto sobre la probabilidad de reingreso hospitalario al a&#241;o no se demuestra en este trabajo&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Laymito-Quispe RdP&#44; L&#243;pez-Vilella R&#44; S&#225;nchez-L&#225;zaro I&#44; Donoso-Trenado V&#44; Lozano-Edo S&#44; Mart&#237;nez-Dolz L&#44; et al&#46; Implicaciones pron&#243;sticas de la hipo e hiperpotasemia en la insuficiencia card&#237;aca aguda con fracci&#243;n de eyecci&#243;n reducida&#46; An&#225;lisis de la mortalidad cardiovascular y reingresos hospitalarios&#46; Med Clin &#40;Barc&#41;&#46; 2022&#59;158&#58;211&#8211;217&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Algorithm for selecting patients with heart failure according to their potassium levels&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">LVEF&#58; left ventricular ejection fraction&#59; HF&#58; heart failure&#59; LVAD&#58; left ventricular assist devices&#59; HT&#58; heart transplant&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Survival curves according to study groups&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">They show significant differences between hypokalaemia&#44; hyperkalaemia and normal potassium levels measured on admission for acute heart failure&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">ARNi&#58; neprilysin and angiotensin receptor inhibitor&#59; ARBs&#58; angiotensin II receptor blockers&#59; BBs&#58; beta blockers&#59; CA125&#58; cancer antigen 125&#59; ICD&#58; implantable cardioverter defibrillator&#59; DM2&#58; type 2 diabetes mellitus&#59; COPD&#58; chronic obstructive pulmonary disease&#59; LVEF&#58; left ventricular ejection fraction&#59; Hb&#58; haemoglobin&#59; HBP&#58; high blood pressure&#59; ACEIs&#58; angiotensin converting enzyme inhibitors&#59; HF&#58; heart failure&#59; SGLT2i&#58; sodium-glucose cotransporter-2 inhibitors&#59; NYHA&#58; New York Heart Association&#44; DBP&#58; diastolic blood pressure&#59; SBP&#58; systolic blood pressure&#59; CRT&#58; cardiac resynchronization therapy&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">202 &#40;34&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Non-ischemic cardiomyopathy&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Valvular heart disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Congenital heart disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Previous cardiac surgery&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Dyslipidemia&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Smoking</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a><span class="elsevierStyleItalic">&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Alcoholism</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a><span class="elsevierStyleItalic">&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Obesity &#40;BMI&#8239;&#62;</span>&#8239;<span class="elsevierStyleItalic">30&#41;&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antidiabetics &#40;not SGLT2i&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Non-HF related&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;31&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypokalaemia vs&#46; normokalaemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypokalaemia vs&#46; normokalaemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;06&nbsp;\t\t\t\t\t\t\n
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                  """
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hyperkalaemia vs&#46; normokalaemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;98&#8722;3&#46;51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;055&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Creatinine&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;1&#8722;1&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;012&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;0&#8722;1&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Readmission for heart failure</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hyperkalaemia vs&#46; normokalaemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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