Optimizing Mineralocorticoid Receptor Antagonist Therapy in Heart Failure Through Integrated Care Strategies

Hyperkalemia is a critical barrier to mineralocorticoid receptor antagonist (MRA) optimization in heart failure (HF) patients with reduced ejection fraction (HFrEF).

The objective of the study was to explore and evaluate a pragmatic, interdisciplinary strategy to safely optimize MRA use in high-risk patients.

We conducted a prospective, observational study comparing patients at risk of hyperkalemia with HFrEF who were exposed to structured MRA titration, via dietitian-guided potassium restriction, remote monitoring, and potassium binder use, to a propensity-matched cohort followed on Medly, a telemonitoring program. A matched win-ratio was applied to assess the hierarchical composite outcome between the 2 cohorts. Outcomes evaluated were MRA optimization, left ventricular ejection fraction improvement, hyperkalemia events, and HF-related hospitalizations.

Among 185 patients (51 exposure and 134 Medly), the exposure group had a higher baseline potassium (5.1 vs 4.2 mmol/L, P < 0.001) and a higher use of potassium binders compared to the Medly group (53% vs 7%, P < 0.001). After 1:1 propensity matching (82 pairs), the exposure cohort had significantly higher MRA optimization rates (HR: 4.67; 95% CI: 1.93-11.27; P < 0.001), and fewer HF hospitalizations (P = 0.014). The composite win ratio which included death, HF hospitalization, left ventricular ejection fraction improvement, and hyperkalemic events significantly favored the exposure group (2.5; 95% CI: 1.3-6.35; P = 0.005).

A multidisciplinary approach combining dietary counseling, remote monitoring, and potassium binders was associated with improved optimization of MRA therapy in HFrEF patients at risk of hyperkalemia. This model may offer potential clinical benefit and underscores the value of team-based care in HF management.