title: Serum potassium, cardiovascular risk, and effects of an ACE inhibitor: results of the HOPE study.
abstract: BACKGROUND
  Both hyper- and hypokalemia increase cardiovascular risk. Modest hyperkalemia is common with angiotensin-converting enzyme inhibition. We studied post-hoc the association of an initial, on-treatment serum potassium measurement with subsequent cardiovascular outcomes over 4.5 years in 9297 individuals at high cardiovascular risk, randomized to an ACE inhibitor or to placebo.
  
  
  METHODS
  Post-hoc analysis of cardiovascular outcomes, as related to serum potassium levels, in the HOPE (Heart Outcomes and Prevention Evaluation) study which compared ramipril to placebo, and included 692 patients with a serum potassium level >5.0 mM and 137 with a serum potassium level <3.5 mM, defined as hyper- and hypokalemia, respectively. Serum potassium was measured 1 month after start of randomized treatment.
  
  
  RESULTS
  With hyperkalemia, the primary event rate was unchanged compared to normokalemia (15.5 vs 15.7%, p > 0.4, respectively), with hypokalemia, the primary event rate was higher (22.6% vs 15.5%, respectively, p = 0.023). The hazard ratio for the primary outcome associated with this initial hypokalemia was 1.44 (1.00-2.06) on multivariate analysis. The combined primary outcome (myocardial infarction, cardiovascular death, stroke) was not different throughout deciles of serum potassium but the lowest and highest deciles included many with normokalemia. Randomized treatment was withheld because of hyperkalemia in 8 and 6 people allocated to ramipril and placebo, respectively. The benefit of ramipril on cardiovascular outcomes was independent of serum potassium, but ramipril reduced hypokalemia in the entire cohort (1.15 vs 1.86% with placebo, p = 0.005), particularly in those participants on diuretics (3.8% vs 6.5%, p = 0.07).
  
  
  CONCLUSIONS
  In patients at high cardiovascular risk, modest hypokalemia predicts a less favorable outcome while modest hyperkalemia does not. Ramipril reduces hypokalemia and decreases risk.
authors.affiliation: Department of Nephrology, Schwabing General Hospital, Ludwig Maximilians University, Munich, Germany.
authors.forename: J F E
authors.initials: JF
authors.lastname: Mann
authors.forename: Q L
authors.initials: QL
authors.lastname: Yi
authors.forename: P
authors.initials: P
authors.lastname: Sleight
authors.forename: G R
authors.initials: GR
authors.lastname: Dagenais
authors.forename: H C
authors.initials: HC
authors.lastname: Gerstein
authors.forename: E M
authors.initials: EM
authors.lastname: Lonn
authors.forename: J
authors.initials: J
authors.lastname: Bosch
mesh_terms: D000368:Aged; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000009:adverse effects*; D002318:Cardiovascular Diseases / Q000097:blood / Q000209:etiology* / Q000517:prevention & control; D005260:Female; D006801:Humans; D006947:Hyperkalemia / Q000139:chemically induced / Q000150:complications*; D007008:Hypokalemia / Q000150:complications* / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D011188:Potassium / Q000097:blood; D017257:Ramipril / Q000009:adverse effects*; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D017257:Ramipril; D011188:Potassium