Review Article : Sacubitril/valsartan use for the hospitalist

Abstract

The mainstays of therapy for heart failure with reduced ejection fraction (HFrEF) have traditionally been angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), beta-blockers, aldosterone receptor antagonists, and diuretics for symptomatic relief (1). With few advances made over the past few decades, the principles of treating HFrEF have been revolutionized following the results of the PARADIGM-HF trial (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) in 2014. The trial compared the novel agent sacubitril/valsartan (Entresto(R)) to Enalapril (1). Sacubitril/valsartan is a combination angiotensin II receptor blocker-neprilysin inhibitor (ARNI) that replaces traditional ACEI and ARB therapy in the treatment of HFrEF. The PARADIGM-HF trial was stopped early due to overwhelming evidence of decreased mortality and decreased HFrEF related hospitalizations with sacubitril/valsartan when compared to Enalapril (2). Since the study was released, the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America (HFSA) released updated guidelines in May 2016. Sacubitril/valsartan now holds a Class I Recommendation for the treatment of HFrEF in patients with New York Heart Association (NYHA) class II or III heart failure (3). These recommendations were further upheld in the recently released 2017 ACC/AHA/HFSA Focused Update for the Management of Heart Failure (4).