BACKGROUND: The interaction between chronic medications on admission and the association between serum potassium level and outcome in patients with acute heart failure (AHF) are unknown. METHODS: Observational intercontinental study of patients admitted with AHF. 15954 patients were included from 12 cohorts in 4 continents. Main outcome was 90-day mortality. Clinical presentation (medication use, hemodynamics, comorbidities), demographic, echocardiographic, and biochemical data on admission were recorded prospectively in each cohort, with prospective adjudication of outcomes. RESULTS: Positive and negative linear relationships between 90-day mortality and sK+ above 4.5 mmol/L (hyperkalemia) and below 3.5 mmol/L (hypo-kalemia) were observed. Hazard ratio for death was 1.46 [1.34-1.58] for hyperkalemia and 1.22 [1.06-1.40] for hypokalemia. In a fully adjusted model, only hyperkalemia remained associated with mortality (HR 1.03 [1.02-1.04] for each 0.1 mmol/l change of sK+ above 4.5 mmol/L). Interaction tests revealed that the association between hyperkalemia and outcome was significantly affected by chronic medications. The association between hyperkalemia and mortality was absent for patients treated with beta blockers and in those with preserved renal function. CONCLUSIONS: In patients with AHF, sK+ > 4.5 mmol/L appears to be associated with 90-day mortality. B-blockers have potentially a protective effect in the setting of hyperkalemia.

ANMCO Research Center Firenze Italy

Baylor College of Medicine Houston TX USA

Cardiology Helsinki University and Helsinki University Hospital Heart and Lung Center Helsinki Finland

Department of Anesthesiology and Critical Care and Burn Unit St Louis Hospital Assistance Publique Hôpitaux de Paris Paris France AP HP Groupe Hospitalier Saint Louis Lariboisière Fernand Widal Paris France

Department of Anesthesiology and Critical Care and Burn Unit St Louis Hospital Assistance Publique Hôpitaux de Paris Paris France AP HP Groupe Hospitalier Saint Louis Lariboisière Fernand Widal Paris France Université Paris Diderot Sorbonne Paris Cité Paris France UMR 942 INSERM Paris France

Department of Cardiac Sciences College of Medicine King Fahad Cardiac Center King Saud University Riyadh Saudi Arabia

Department of Cardiology and Cardiovascular Research Institute Basel University Hospital Basel Switzerland

Department of Cardiology Hôpitaux Universitaire Saint Louis Lariboisière Assistance Publique des Hôpitaux de Paris Paris France

Department of Internal Medicine and Cardiology University Hospital Brno Brno Czech Republic Faculty of Medicine Masaryk University Brno Czech Republic

Division of Cardiology Department of Internal Medicine Cardiovascular Center Seoul National University Bundang Hospital Seoul South Korea

Division of Nephrology Ambroise Paré university hospital APHP University of Paris Ouest Versailles St Quentin en Yvelines Univ Paris Sud UVSQ Université Paris Saclay Villejuif France

Emergency Department Hôpitaux Universitaire Saint Louis Lariboisière Assistance Publique des Hôpitaux de Paris Paris France

Emergency Department Hospital Clinic and 'Emergency care processes and diseases' Research Group IDIBAPS Barcelona Catalonia Spain

INSERM Centre d'Investigations Cliniques Plurithématique 1433 INSERM U1116 Université de Lorraine CHRU de Nancy F CRIN INI CRCT Nancy France

Nippon Medical School Musashi Kosugi Hospital Kanagawa Japan

Saint Luke's Mid America Heart Institute and University of Missouri Kansas City Kansas MO USA

Sociedad Argentina de Cardiologia Area de Investigacion SAC Azcuenaga Buenos Aires Argentina

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