AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Time in Normal-High Potassium Range and Cardiovascular Outcomes in Cardio-Kidney-Metabolic Syndrome: A FINE-HEART Analysis
By Lu H, Claggett B, Filippatos G et al.
Background: Serum potassium is a known prognostic marker in patients with heart failure (HF) and chronic kidney disease (CKD), with both hypo- and hyperkalemia associated with adverse outcomes. The POTCAST trial demonstrated that targeting a potassium range of 4.5-5.0 mmol/L may be optimal in patients at high risk for ventricular arrhythmias. Research Questions: We investigated the association between potassium control—defined as time-in-target range (TIR) within 4.5-5.0 mmol/L—and subsequent CV outcomes among broader risk patients with cardio-kidney-metabolic syndrome. Methods: We pooled individual participant data from three randomized clinical trials comparing finerenone with placebo. FIDELIO-DKD and FIGARO-DKD enrolled adults with type 2 diabetes (T2D) and albuminuric CKD, with urinary albumin-to-creatinine ratio 30-5,000 mg/g and trial-specific estimated glomerular filtration rate ranging from 25 to ≥90 mL/min/1.73 m ² . FINEARTS-HF enrolled adults aged ≥40 years with symptomatic HF and LVEF ≥40%, irrespective of T2D status. For each participant, daily serum potassium values during the first year after randomization were estimated by interpolation between scheduled potassium measurements obtained at prespecified study visits (mean # of visits per patient 5.3 ± 1.3 in FINEARTS-HF, 4.8 ± 0.7 in FIDELIO-DKD/FIGARO-DKD). The TIR within 4.5-5.0 mmol/L was then calculated for each participant. The continuous association between individual-level TIR during the first year and subsequent risk of the composite outcome of first HF hospitalization or CV death and its individual components, was assessed using landmark Cox proportional hazards models with linear splines, adjusted for covariates including baseline potassium levels, trial, and randomized treatment arm. Results: Among 18,991 participants (mean age 67±10 years; 35% women), the median TIR during the first year was 32%, corresponding to ≈117 days. Randomization to finerenone increased TIR by 8% (95% CI 7-9) compared with placebo, with a rightward shift in the distribution of potassium TIR (median 38% vs. 23%; Fig 1). Higher TIR was independently associated with a lower subsequent risk of the composite of HF hospitalization or CV death (P=0.006; Fig 2A) which appeared driven by lower risks of CV death (P=0.042; Fig 2B) compared with HF hospitalization (P=0.23; Fig 2C). Doubling in potassium TIR was associated with a 20% lower risk of the composite outcome (HR 0.80, 95% CI 0.70-0.92, P=0.001). Conclusions: In nearly 19,000 patients enrolled in the FINE-HEART program, greater sustained control of serum potassium between 4.5-5.0 mmol/L was independently associated with a lower subsequent risk of cardiovascular events, mainly driven by lower CV death. These data support prospective testing of a strategy of targeting high-normal potassium levels across a broader risk population with cardio-kidney-metabolic syndrome.