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Circulation. 2018 Mar 27;137(13):1320-1330. doi: 10.1161/CIRCULATIONAHA.117.030576. Epub 2017 Oct 12.

Long-Term Potassium Monitoring and Dynamics in Heart Failure and Risk of Mortality.

Author information

Cardiology Department, Hosfpital Clínico Universitario de Valencia, INCLIVA. Departamento de Medicina, Universitat de València, Spain (J.N., E.N., V.B., G.M., E.S., F.J.C., A.M., J.S.)
CIBER in Cardiovascular Diseases (CIBERCV), Madrid, Spain (J.N., A.B.-G., G.M., A.M., J.L., J.S.).
Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain, and Department of Medicine, Autonomous University of Barcelona, Spain (A.B.-G., J.L.).
Inserm, Centre d'Investigation Clinique Plurithématique 1433, Inserm U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, France (F.Z., P.R.).
Cardiology Department, Hosfpital Clínico Universitario de Valencia, INCLIVA. Departamento de Medicina, Universitat de València, Spain (J.N., E.N., V.B., G.M., E.S., F.J.C., A.M., J.S.).
Biochemistry Department, Hospital Clínico Universitario de Valencia, INCLIVA, Spain (A.C.).
Hospital Clínico Universitario, Universitat de València, INCLIVA, Spain. CIBERESP (J.N.).
Nephrology Department, Hospital Clínico Universitario, INCLIVA, Department of Medicine, Universitat de València, Spain (J.L.G.).
Klinik für Herz- und Kreislauferkrankungen, Deutsches Herzzentrum München, Technical University Munich, Germany (O.H.).
Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Italy (M.M.).



The prognostic value of long-term potassium monitoring and dynamics in heart failure has not been characterized completely. We sought to determine the association between serum potassium values collected at follow-up with all-cause mortality in a prospective and consecutive cohort of patients discharged from a previous acute heart failure admission.


Serum potassium was measured at every physician-patient encounter, including hospital admissions and ambulatory settings. The multivariable-adjusted association of serum potassium with mortality was assessed by using comprehensive state-of-the-art regression methods that can accommodate time-dependent exposure modeling.


The study sample included 2164 patients with a total of 16 116 potassium observations. Mean potassium at discharge was 4.3±0.48 mEq/L. Hypokalemia (<3.5 mEq/L), normokalemia (3.5-5.0 mEq/L), and hyperkalemia (>5 mEq/L) were observed at the index admission in 77 (3.6%), 1965 (90.8%), and 122 (5.6%) patients, respectively. At a median follow-up of 2.8 years (range, 0.03-12.8 years), 1090 patients died (50.4%). On a continuous scale, the multivariable-adjusted association of potassium values and mortality revealed a nonlinear association (U-shaped) with higher risk at both ends of its distribution (omnibus P=0.001). Likewise, the adjusted hazard ratios for hypokalemia and hyperkalemia, normokalemia as reference, were 2.35 (95% confidence interval, 1.40-3.93; P=0.001) and 1.55 (95% confidence interval, 1.11-2.16; P=0.011), respectively (omnibus P=0.0003). Furthermore, dynamic changes in potassium were independently associated with substantial differences in mortality risk. Potassium normalization was independently associated with lower mortality risk (P=0.001).


Either modeled continuously or categorically, serum potassium levels during long-term monitoring were independently associated with mortality in patients with heart failure. Likewise, persistence of abnormal potassium levels was linked to a higher risk of death in comparison with patients who maintained or returned to normal values.


cohort studies; heart failure; hyperkalemia; hypokalemia; longitudinal studies; mortality; potassium

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