Triple blockade of the renin-angiotensin system – don’t!

Introduction: Drug-induced hyperkalemia is a common side-effect during the treatment with drugs interacting with the renin-angiotensin system (RAS) and sometimes can become life threatening for the patient.
Case presentation: We present the case of a 83 years old patient, diabetic (undergoing treatment with met-formin) and hypertensive (undergoing treatment with an ACE inhibitor, an ARB and spironolactone). He is addressed by the family for anterior thoracic pain star-ted 2 hours previous to the presentation.
Clinically, the patient can hardly cooperate, HR 20b/ min, BP 160/100 mmHg. Blood tests revealed severe hyperkalemia (K 8.1 mEq/l) with ECG expression: to-tal AV block, 20b/min. Also, he associates severe metabolic acidosis (BE 8 mmol/l, lactate 11,1 mmol/l, pH 7,16), eGFR 25 ml/min/1.73 m2, hyperglycemia, mini-mal myocardial and hepatic cytolysis and inflammatory syndrome. Temporary cardiac pacing was performed, and a central jugular catheter was inserted in order to initiate hemodialysis. After two sessions of dialysis, acido-basic, fluid and electrolyte imbalances were cor-rected and the ECG showed intermittent Mobitz II AV block.The echocardiography showed a normal systolic function of the LV – EF 60%, without any kinetic abnormalities, pericardial fluid or valvular diseases. A 24h Holter ECG monitoring was performed, which revealed intermittent Mobitz II AV block and multiple PVCs, systematized in couplets, triplets and episodes of unstained ventricular tachycardia. Therefore, permanent cardiac pacing was performed, with no procedural complications. Then, the evolution was favorable, once all the associated comorbidities were stabilized.
Conclusions: The present case underlines the importance of bearing in mind the interactions, side effects and contraindications of the drugs we frequently use in everyday practice. Also, it shows the positive impact of the collaboration between the cardiologist and the nephrologist for solving cases that involve both medical fields.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
ESC search engine
CODE: 379
CME Credits: 10 (Romanian College of Physicians)