Transitions Squared: Transitioning Sacubitril/Valsartan at Transitions of Care

One of the questions that remained unanswered after the PARADIGM-HF trial was whether the angiotensin receptor/neprilysin inhibitor sacubitril/valsartan could be safely initiated in patients with acute decompensated heart failure who had been previously stabilized on an angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker. In this blog, Dr. Reed discusses the implications of the PIONEER-HF and TRANSITION studies, and provides a practical strategy for transitioning patients to sacubitril/valsartan.

Titration of Renin-Angiotensin System Inhibitors in Patients with Heart Failure with Reduced Ejection Fraction and an “At-Goal” Blood Pressure

Initiation and titration of guideline-directed medical therapy is paramount for patients with heart failure with reduced ejection fraction (HFrEF), as it reduces the risk of death and other complications. Despite this, many patients do not receive the appropriate therapies or doses due to concerns and/or misconceptions about the use of these therapies. One reason often cited for not using or titrating inhibitors of the renin-angiotensin system is that blood pressure is already “at goal” or is “too low”. In this blog, the data surrounding titration of angiotensin converting enzyme inhibitors, angiotensin II receptor blockers and the angiotensin II receptor blocker/neprilysin inhibitor in patients with HFrEF will be addressed.

A Problem in PARADIGM-HF: What about Black Patients?

In PARADIGM-HF, a combination of the neprilysin inhibitor sacubitril and the angiotensin receptor blocker valsartan reduced cardiovascular death and hospitalizations for heart failure compared to the ACE inhibitor enalapril. But by studying so few black patients, who have historically responded less favorably to many heart failure drugs, can we trust its widespread use in this population?