Introduction: Angiotensin converting enzyme inhibitors (ACE-i)/sartans are frequently associated with mineralocorticoid receptor antagonists (MRA) for the treatment of heart failure with reduced ejection fraction. Occasionally, the risk is greater than the benefit, especially in the elderly population with renal impairment.
Case presentation: We will present the case of a 77 years old female patient, known with diabetes mellitus, arterial hypertension, with aortic mechanical valve re-placement and Biermer’s anemia, who was under treatment with sartan, beta blocker, MRA, oral anticoagulant and B12 vitamin. The patient was addressed to our hospital for new onset of third-degree atrioventricular block, with cerebral hypoperfusion symptoms and wi-thout syncope. At presentation, BP was 105/40 mmHg, HR 40 bpm, SpO₂ 93%. Auscultation revealed a systo-lic murmur in the aortic and mitral area. Biologically, anemia (Hb 7 g/dl), renal impairment (Creatinine Clearance 26 ml/min/1.73 m²), severe hiperkalemia (K 9.3 mmoli/l), metabolic acidosis and Na⁺ 133 mmoli/l were assessed. The electrocardiogram demonstrated third-degree atrioventricular block, HR 40 bpm, wide QRS complex. The echocardiograhy showed left ventricular hypertrophy, EF 40%, aortic valve prosthesis with high Doppler velocity and gradients (peak velocity 3,6 m/s, peak gradient 52 mmHg, mean gradient 22 mmHg), moderate mitral and tricuspid valve regurgitation and a high probability of pulmonary hypertension. The patient received loop diuretic, sodium bicarbonate, glucose with insulin, calcium gluconate. Afterwards, we performed emergency hemodialysis, witch led to a decreasing of potassium level to 4.6 mmoli/l, PH normalization and resuming of sinus rhythm. Subsequent Holter monitoring showed no conduction abnormality.
Conclusions: Severe hyperkalemia represents a medical emergency. Undelayed treatment, including in some cases hemodialysis is mandatory. We want to emphasize the life threatening risk associated with the dual aldosterone blockade in an elderly, frail patient and the importance of close monitoring.