BACKGROUND: Hyperkalemia (HK) is associated with suboptimal renin-angiotensin system (RAS) inhibitor and mineralocorticoid receptor antagonist (MRA) use in heart failure with reduced ejection fraction (HFrEF). OBJECTIVES: This study sought to assess characteristics and RAS inhibitor/MRA use in patients receiving patiromer during the DIAMOND (Patiromer for the Management of Hyperkalemia in Subjects Receiving RAASi Medications for the Treatment of Heart Failure) run-in phase. METHODS: Patients with HFrEF and HK or past HK entered a run-in phase of ≤12 weeks with patiromer-facilitated RAS inhibitor/MRA optimization to achieve ≥50% recommended RAS inhibitor dose, 50 mg/d MRA, and normokalemia. Patients achieving these criteria (randomized group) were compared with the run-in failure group (patients not meeting the randomization criteria). RESULTS: Of 1,038 patients completing the run-in, 878 (84.6%) were randomized and 160 (15.4%) were run-in failures. Overall, 422 (40.7%) had HK entering run-in with a similar frequency in the randomized and run-in failure groups (40.3% vs 42.5%; P = 0.605). From start to the end of run-in, in the randomized group, an increase was observed in target RAS inhibitor and MRA use in patients with HK (RAS inhibitor: 76.8% to 98.6%; MRA: 35.9% to 98.6%) and past HK (RAS inhibitor: 60.5% to 98.1%; MRA: 15.6% to 98.7%). Despite not meeting the randomization criteria, an increase after run-in was observed in the run-in failure group in target RAS inhibitor (52.5% to 70.6%) and MRA use (15.0% to 48.1%). This increase was observed in patients with HK (RAS inhibitor: 51.5% to 64.7%; MRA: 19.1% to 39.7%) and past HK (RAS inhibitor: 53.3% to 75.0%; MRA: 12.0% to 54.3%). CONCLUSIONS: In patients with HFrEF and HK or past HK receiving suboptimal RAS inhibitor/MRA therapy, RAS inhibitor/MRA optimization increased during patiromer-facilitated run-in.

Cardiology ASST Spedali Civili and University Brescia Italy

Cardiology Department Hospital Universitari Germans Trias i Pujol Badalona Barcelona CIBERCV Barcelona Spain

Central Michigan University College of Medicine Mount Pleasant Michigan USA

Clinic of Cardiology and Angiology General University Hospital Prague Prague Czech Republic

CSL Vifor Glattbrugg Switzerland

CSL Vifor Redwood City California USA

Department of Cardiology partner site Berlin Charité Universitätsmedizin Berlin Germany

Department of Cardiology University Medical Center Groningen Groningen the Netherlands

Department of Cardiovascular Disease Saint Luke's Mid America Heart Institute and University of Missouri Kansas City Kansas City Missouri USA

Department of Medical Statistics University Medical Center Göttingen Göttingen Germany; DZHK partner site Göttingen Göttingen Germany

Department of Medicine Duke University School of Medicine Durham North Carolina USA

Department of Medicine Unit of Cardiology Karolinska Institutet Solna Sweden; Department of Cardiology Karolinska University Hospital Stockholm Sweden

Department of Medicine University of Mississippi Jackson Mississippi USA

Division of Cardiology University of Michigan Ann Arbor Michigan USA

Division of Nephrology Department of Medicine University of Maryland School of Medicine Baltimore Maryland USA

Erasmus MC University Medical Center Rotterdam the Netherlands

Faculty of Medicine and Dentistry University of Alberta Edmonton Alberta Canada

Heart Research Institute Sydney Australia

INECO Neurociencias Oroño Rosario Santa Fe Argentina

Institute of Heart Diseases Wroclaw Medical University Wroclaw Poland

Klinik für Innere Medizin 3 Saarland University Homburg Saar Germany

Medical Specialties and Nephrology Departments Princess Grace Hospital and Monaco Private Hemodialysis Centre Monaco; Université de Lorraine Centre d'Investigations Cliniques Plurithématique 14 33 Inserm U1116 CHRU Nancy France and F CRIN INI CRCT Nancy France

National and Kapodistrian University of Athens School of Medicine Athens University Hospital Attikon Athens Greece

Santa Maria University Hospital CAML CCUL Faculdade de Medicina da Universidade de Lisboa Lisbon Portugal

University of Milano Bicocca Cardiovascular Department Papa Giovanni XXIII Hospital Bergamo Italy

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