RELieving Increasing oEdema Due to Heart Failure

Inclusion Criteria

• •A. For the Screening Log (no follow-up envisaged nor linkage to electronic medical records)
• •1. ≥18 years
• •2. Heart failure in the investigators opinion (new onset or decompensated chronic heart failure)
• •3. Planned to receive\>80mg/day of furosemide or equivalent (IV, SC or oral) in the next 24 hours.
• •4. Worsening symptoms \& signs of congestion in the prior 10 days requiring at least one of the following:
• •1. hospitalisation
• •2. administration of intravenous diuretics
• •3. an increase in the dose of loop diuretic by at least 40mg/day of furosemide (or equivalent) to a total of at least 80mg/day of furosemide (or equivalent)
• •4. addition of a thiazide diuretic to treatment with a loop diuretic
• •B. For the Consented Registry (with linkage to electronic medical records)
• •1. Fulfils the criteria for the screening log
• •2. Able and willing to provide written informed consent for registry participation
• •C. For Randomised Trial Run-in
• •1. Fulfils criteria for the consented registry
• •2. Clinical diagnosis of heart failure for at least 4 weeks
• •3. Congestion as shown by at least one of the following:
• •1. Peripheral oedema
• •2. Raised venous pressure
• •3. Inferior vena cava diameter \>20mm
• •4. Cardiac dysfunction documented by at least one of the following in the previous three years:
• •1. A LVEF\<50%or a report of moderate or severe left ventricular dysfunction
• •2. Left atrial diameter \>3.0cm/m2 (body surface area)
• •3. Elevated BNP or NT-proBNP (BNP \>150ng/L if in sinus rhythm or \>450ng/L if not in sinus rhythm; NT-proBNP \>500ng/L if in sinus rhythm and \>1500ng/L if not in sinus rhythm)
• •5. Able and willing to provide written informed consent for the randomised trial
• •D. For Randomisation
• •1. Serum potassium \>5.0mmol/L
• •* Patients with a serum potassium \>5.0mmol/L may be randomised immediately unless they have severe hyperkalaemia requiring, in the investigators opinion, intravenous treatment or a potassium binding agent.
• •* Severe hyperkalaemia should be managed according to the UK Renal Association guidelines of 2014 (https://renal.org/wp-content/uploads/2017/06/hyperkalaemia-guideline-1.pdf). Participants may be reconsidered for the trial once such interventions are no longer considered necessary.
• •* Patients with a serum potassium ≤5.0mmol/L should be initiated on spironolactone or have the dose increased up to 100mg/day and randomised only if serum potassium exceeds 5.0mmol/L. Those intolerant of or unwilling to take spironolactone should be offered eplerenone titrated to a maximum dose of 50mg/day.
• •* A run-in period of up to 35 days is permitted (the run-in period will usually occur during hospitalisation or a course of day-care or intense management).
• •2. After ingestion of a test-dose of patiromer,
• •1. the patient is willing to continue in the trial
• •2. the investigator considers the patient can follow instructions on preparing patiromer