Skip to main content
Top

30-01-2025 | Hyperkalemia | Mini Review

Sodium zirconium cyclosilicate for MRAs optimization in HFrEF: lessons learned from the REALIZE-K trial

Authors: Luca Monzo, Francesca Musella, Nicolas Girerd, Patrick Rossignol

Published in: Heart Failure Reviews

Login to get access

Abstract

Mineralocorticoid receptor antagonists (MRAs) are a cornerstone of guideline-directed medical therapy for heart failure with reduced ejection fraction (HFrEF), offering significant benefits in reducing mortality and hospitalizations. However, their use is often constrained by the risk of hyperkalemia, particularly in patients with chronic kidney disease. Patiromer and sodium zirconium cyclosilicate (SZC), two novel potassium binders, have emerged as highly effective and safe tools for managing hyperkalemia and enabling the optimization of MRA therapy. This mini-review critically examines the findings of the recently published REALIZE-K (Randomized Withdrawal Trial Evaluating Sodium Zirconium Cyclosilicate for the Management of Hyperkalemia in Patients With Symptomatic Heart Failure With Reduced Ejection Fraction and Receiving Spironolactone) trial, placing it within the broader context of current evidence on potassium binders and their potential role in mitigating hyperkalemia to optimize MRA treatment. Moreover, it explores other significant barriers to MRA optimization, including clinician concerns over the risk of hyperkalemia, a consistent and pervasive issue that often leads to treatment inertia. By addressing both physiological and psychological barriers, this review aims to provide a comprehensive understanding of how to enhance MRA utilization and potentially improve clinical outcomes in patients with HFrEF.
Literature
5.
7.
go back to reference Guidetti F, Lund LH, Benson L et al (2023) Safety of continuing mineralocorticoid receptor antagonist treatment in patients with heart failure with reduced ejection fraction and severe kidney disease: data from Swedish Heart Failure Registry. Eur J Heart Fail 25:2164–2173. https://doi.org/10.1002/ejhf.3049CrossRefPubMed Guidetti F, Lund LH, Benson L et al (2023) Safety of continuing mineralocorticoid receptor antagonist treatment in patients with heart failure with reduced ejection fraction and severe kidney disease: data from Swedish Heart Failure Registry. Eur J Heart Fail 25:2164–2173. https://​doi.​org/​10.​1002/​ejhf.​3049CrossRefPubMed
9.
go back to reference Monzo L, Bresso E, Dickstein K, Pitt B, Cleland JGF, Anker SD, Lam CSP, Mehra MR, van Veldhuisen DJ, Greenberg B, Zannad F, Girerd N (2024) Machine learning approach to identify phenotypes in patients with ischaemic heart failure with reduced ejection fraction. Eur J Heart Fail. https://doi.org/10.1002/ejhf.3547 Monzo L, Bresso E, Dickstein K, Pitt B, Cleland JGF, Anker SD, Lam CSP, Mehra MR, van Veldhuisen DJ, Greenberg B, Zannad F, Girerd N (2024) Machine learning approach to identify phenotypes in patients with ischaemic heart failure with reduced ejection fraction. Eur J Heart Fail. https://​doi.​org/​10.​1002/​ejhf.​3547
14.
go back to reference Authors/Task Force M, McDonagh TA, Metra M et al (2022) 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 24:4-131. https://doi.org/10.1002/ejhf.2333 Authors/Task Force M, McDonagh TA, Metra M et al (2022) 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). With the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 24:4-131. https://​doi.​org/​10.​1002/​ejhf.​2333
19.
go back to reference Rossignol P, Lainscak M, Crespo-Leiro MG et al (2020) Unravelling the interplay between hyperkalaemia, renin-angiotensin-aldosterone inhibitor use and clinical outcomes. Data from 9222 chronic heart failure patients of the ESC-HFA-EORP Heart Failure Long-Term Registry. Eur J Heart Fail 22:1378–1389. https://doi.org/10.1002/ejhf.1793CrossRefPubMed Rossignol P, Lainscak M, Crespo-Leiro MG et al (2020) Unravelling the interplay between hyperkalaemia, renin-angiotensin-aldosterone inhibitor use and clinical outcomes. Data from 9222 chronic heart failure patients of the ESC-HFA-EORP Heart Failure Long-Term Registry. Eur J Heart Fail 22:1378–1389. https://​doi.​org/​10.​1002/​ejhf.​1793CrossRefPubMed
32.
go back to reference Rossignol P, Williams B, Mayo MR et al (2020) Patiromer versus placebo to enable spironolactone use in patients with resistant hypertension and chronic kidney disease (AMBER): results in the pre-specified subgroup with heart failure. Eur J Heart Fail 22:1462–1471. https://doi.org/10.1002/ejhf.1860CrossRefPubMed Rossignol P, Williams B, Mayo MR et al (2020) Patiromer versus placebo to enable spironolactone use in patients with resistant hypertension and chronic kidney disease (AMBER): results in the pre-specified subgroup with heart failure. Eur J Heart Fail 22:1462–1471. https://​doi.​org/​10.​1002/​ejhf.​1860CrossRefPubMed
33.
47.
go back to reference Rossignol P, Dobre D, McMurray JJ et al (2014) Incidence, determinants, and prognostic significance of hyperkalemia and worsening renal function in patients with heart failure receiving the mineralocorticoid receptor antagonist eplerenone or placebo in addition to optimal medical therapy: results from the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF). Circ Heart Fail 7:51–58. https://doi.org/10.1161/CIRCHEARTFAILURE.113.000792CrossRefPubMed Rossignol P, Dobre D, McMurray JJ et al (2014) Incidence, determinants, and prognostic significance of hyperkalemia and worsening renal function in patients with heart failure receiving the mineralocorticoid receptor antagonist eplerenone or placebo in addition to optimal medical therapy: results from the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF). Circ Heart Fail 7:51–58. https://​doi.​org/​10.​1161/​CIRCHEARTFAILURE​.​113.​000792CrossRefPubMed
Metadata
Title
Sodium zirconium cyclosilicate for MRAs optimization in HFrEF: lessons learned from the REALIZE-K trial
Authors
Luca Monzo
Francesca Musella
Nicolas Girerd
Patrick Rossignol
Publication date
30-01-2025
Publisher
Springer US
Published in
Heart Failure Reviews
Print ISSN: 1382-4147
Electronic ISSN: 1573-7322
DOI
https://doi.org/10.1007/s10741-025-10490-6

Keynote series | Spotlight on menopause

Menopause can have a significant impact on the body, with effects ranging beyond the endocrine and reproductive systems. Learn about the systemic effects of menopause, so you can help patients in your clinics through the transition.   

Prof. Martha Hickey
Dr. Claudia Barth
Dr. Samar El Khoudary
Developed by: Springer Medicine
Watch now

A quick guide to ECGs

Improve your ECG interpretation skills with this comprehensive, rapid, interactive course. Expert advice provides detailed feedback as you work through 50 ECGs covering the most common cardiac presentations to ensure your practice stays up to date. 

PD Dr. Carsten W. Israel
Developed by: Springer Medizin
Start the cases

Keynote webinar | Spotlight on medication adherence

  • Webinar | 27-06-2024 | 18:00 (CEST)

Medication non-adherence is a major barrier to effective healthcare delivery; half of all patients do not follow their doctor’s recommendations or treatment plan.

Our experts explain the fundamentals with a practical discussion of how to manage non-adherence in two common scenarios: hypertension and asthma control.

Prof. Kevin Dolgin
Prof. Florian Limbourg
Prof. Anoop Chauhan
Developed by: Springer Medicine
Watch now