Letter regarding the article ‘ Effects of hyperkalaemia and non?adherence to renin–angiotensin–aldosterone system inhibitor therapy in patients with heart failure in Italy : a propensity?matched study’

We read with great interest the paper by Volterrani et al.1 In this observational cohort of heart failure (HF) patients on renin–angiotensin–aldosterone system inhibitors (RAASi), hyperkalaemia had an increased risk cardiovascular events or death. Furthermore, among hyperkalaemia, 77% were not adherent to RAASi therapy in 12 months after index date (the first hospitalization discharge related HF), and these mortality. agree authors' main conclusion that further investigation is required for achieving optimal treatment hyperkalaemic conditions. A limitation study was al. only assessed non-adherence outpatient setting, but acute decompensation. Namely, there who discontinued due before HF-related hospitalization. would like add several comments point. The decision whether withdraw from HF medications hospital-based setting at discretion treating physician may be driven multiple factors, including potassium levels.2 Despite importance process during management hospitalized patients, data surrounding in-hospital are scarce compared medical a stable setting.3-5 our registry-based data-set included 4000 consecutive (West-Tokyo Heart Failure Registry) between 2006 2015, 683 systolic HF, without advanced renal disease (ejection fraction <50% estimated glomerular filtration rate ?30 min/mL/1.73 m2), treated admission. predominantly male (68.4%) median age 74 years (interquartile range: 63, 82 years), their serum levels admission 4.3 mEq/L 4.0, 4.7 mEq/L). On admission, 9.2% (n = 63) (K >5.0 proportions 19.0% 11.6% those (Figure 1A). These results suggest could trigger HF. Meanwhile, over 80% did have irrespective continued (RAASi continuation, 91.0%; discontinuation, 83.3%) 1B). Therefore, it plausible overreaction, predisposing additional risk. There potential room improvement optimization [e.g. enabled strict monitoring level (plus use binders)]. appreciate efforts research also propose performed attain RAASi, while minimizing hyperkalaemia-associated chronic settings, settings.