PEBC MCQ Heart Failure, AF, CAD & Anticoagulation question: week ago alongside sacubitril/valsartan

PEBC MCQHeart Failure, AF, CAD & Anticoagulation

EB, 74, with HFrEF, started spironolactone 12.5 mg daily 1 week ago alongside sacubitril/valsartan. Today potassium is 5.8 mmol/L (previously 4.6) and creatinine has risen 15%. Which of the following is the most appropriate action?

a. Hold spironolactone and recheck potassium promptly
b. Continue spironolactone and add a potassium-rich diet
c. Double spironolactone to 25 mg since creatinine rose only 15%
d. Stop sacubitril/valsartan permanently and continue spironolactone

Show the answer and explanation

Answer: a. Hold spironolactone and recheck potassium promptly

Hyperkalemia is the main risk of MRAs, especially in older adults on RAS inhibitors. Heart failure guidance and the spironolactone monograph advise holding the MRA when potassium exceeds about 5.5 mmol/L and reassessing; once potassium normalises, a lower dose or alternate-day dosing may be retried. Increasing the dose or adding dietary potassium is dangerous, and permanently stopping the ARNI removes a key mortality-reducing therapy. Source: CCS/CHFS HF guidelines (Ezekowitz JA et al. Can J Cardiol 2017;33:1342 and 2021 update), MRA monitoring; spironolactone product monograph, Warnings: hyperkalemia (DPD, checked 2026).

Common mistake

Continuing an MRA through significant hyperkalemia.

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