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BackgroundWidespread use of angiotensin receptor blocker and neprilysin inhibitor (ARNI) remains low, and many patients are unable to tolerate the medication due to hypotension at the currently recommended starting dose.HypothesisThe aim of this study is to assess if lower than standard doses of ARNI, sacubitril/valsartan (S/V), significantly reduces NT‐proBNP and leads to any change in diuretic dose, serum potassium, or creatinine.MethodsIn a retrospective study of 278 patients who were started on a low dose S/V at a single medical center, 45 patients were selected for the study cohort. Patients were subcategorized to Group 1 (n = 10): very low dose S/V (half a tab of 24/26 mg BID), Group 2 (n = 10): very low dose titrated to low dose S/V, and Group 3 (n = 25): low dose S/V (24/26 mg BID). NT‐proBNP, diuretic dose, serum potassium, and creatinine were compared before and after initiation of S/V.ResultsAmong all groups, there was a significant reduction in NT‐proBNP level (Group 1: p < .01, Group 2: p < .01, and Group 3: p < .001). In addition, there was a significant reduction in diuretic dose across all groups combined (furosemide 53 mg/day vs. 73 mg/day; p = .03), with 17.8% (8/45) patients being able to discontinue their diuretic completely. There was no significant change in potassium or creatinine.ConclusionsLower than standard dose of S/V significantly reduces NT‐proBNP and diuretic requirement without change in potassium or creatinine, which provides hope that patients who cannot tolerate standard doses of S/V due to hypotension may be able to receive the benefits of S/V therapy.

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Background Cardiac allograft vasculopathy (CAV) is a leading cause of graft failure in cardiac transplant recipients. Progression of intimal thickening noted during routine surveillance intracoronary imaging is associated with the development of CAV. However, mechanisms of CAV development are poorly understood and targets for therapy modification remain elusive. We investigated the association of neovessels (INs) within the intima, noted by optical coherence tomography (OCT) during routine CAV surveillance imaging, with intimal thickening and coincident CAV. Methods Coronary angiography and OCT images of 45 consecutive cardiac transplant recipients undergoing surveillance coronary imaging were reviewed. The presence of INs, defined as dark, tubular or rotund intimal structures, measuring 50-200 µm in diameter, noted in at least three OCT frames, was quantified. CAV diagnosis was determined by utilizing the International Society of Heart and Lung Transplant classification system. Demographic and clinical data was obtained by chart review. Significant associations between the presence of INs and CAV, intimal thickening, and demographic features were evaluated.