The Role of Sacubitril/Valsartan in HFrEF

Peter L. Salgo, MD: Let’s talk about the role of the ARNI, sacubitril/valsartan (the only one just now), in heart failure with reduced ejection fraction (HFrEF) patients. Who are the right candidates for this? Is it everybody or is it a select subgroup of folks that you’d start with?

Orly Vardeny, PharmD, MS: Let’s start with what the guidelines tell us to do. The update to the guidelines that came out in 2016 says that patients who are symptomatic, so functional class 2 and 3 heart failure with reduced ejection fraction, who are tolerating an ACE (angiotensin-converting enzyme) inhibitor or an ARB (angiotensin receptor blocker), should be switched.

Peter L. Salgo, MD: I want to make that very clear. This is a big, big recommendation. “Tolerating” should be switched?

Orly Vardeny, PharmD, MS: Correct.

Peter L. Salgo, MD: That’s on the basis of really good results on the study we just talked about?

Orly Vardeny, PharmD, MS: Exactly, a very large study. And meaning that patients who are symptomatic, who are on an ACE inhibitor or ARB and remain symptomatic, should be switched.

Peter L. Salgo, MD: Who should not be switched? Let’s turn it upside down.

Orly Vardeny, PharmD, MS: One of the things that was observed in the trial was about a 10%, correct me if I’m wrong, maybe 11% symptomatic hypotension in patients who were taking sacubitril/valsartan versus enalapril. So, there is a more pronounced blood pressure-lowering effect with sacubitril/valsartan. Patients whose blood pressure is already on the lower side, who may be symptomatic in terms of orthostasis, are not good candidates for switching.

Peter L. Salgo, MD: They could fall over. You don’t want to take somebody who’s just about on the edge of acceptable blood pressure and make that lower.

Scott Solomon, MD: It’s going to be a little more difficult in those patients. It doesn’t mean that you may not want to try, in some, but I think you have to be careful about it. This drug is a potent blood pressure-lowering drug.

Sheryl Chow, PharmD, BCPS: In addition to what Orly had mentioned, clearly, if you have a contraindication to an ACE inhibitor, clearly there needs to be a 36-hour washout period before initiating Entresto. Other contraindications—if you have angioedema and you had angioedema on an ACE inhibitor and, for some strange reason, they switch you over to an ARB and you’re fine—I don’t care if it’s valsartan, it’s still contraindicated and those patients should not be started on Entresto.