New strategies for treatment of heart failure with aldosterone antagonists and the risk of hyperkalaemia.

Since the publication of The Randomized Aldactone Study (RALES) in 1999, the association of angiotensin-converting enzyme (ACE) inhibitors and spironolactone has been largely used for the treatment of congestive heart failure (CHF). Although this study had shown a diminished morbimortality in patients with CHF that are treated with spironolactone and ACE inhibitors and a low risk (2%) of development of severe hyperkalaemia, other clinical studies have shown higher rates of hyperkalaemia and serious adverse clinical events culminating in death. Therefore, the identification of risk factors for the development of hyperkalaemia in CHF patients, close monitoring of serum potassium and determination of renal function before and after the initiation of combined therapy or after a dose increment, should be routinely performed. It is strongly recommended that these drugs be initiated in low doses and that the increment in dose should only occur after considering all safety issues.