Study Objective Despite evidence that supports the use of sacubitril/valsartan – the first angiotensin II receptor blocker–neprilysin inhibitor – for mortality reduction in patients with heart failure (HF), it remains underprescribed. The objective of this study was to evaluate eligibility for initiation of sacubitril/valsartan treatment in patients with HF within the largest Veterans Administration healthcare system in the United States. Design Cross‐sectional study. Setting Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS). Patients A total of 2985 patients with a HF diagnosis who were alive as of November 1, 2017. Measurements and Main Results Eligibility for sacubitril/valsartan initiation was based on inclusion and exclusion criteria from the Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitor with Angiotensin‐Converting–Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM‐HF) trial and the VA Criteria for Use. The proportion of eligible patients was estimated, and characteristics of eligible patients were compared with those in the PARADIGM‐HF trial. Of the 2985 patients with HF who were alive as of November 1, 2017, 965 (32.3%) had HF with reduced ejection fraction (HFrEF). Of these patients with HFrEF, 263 (27.3%) fulfilled eligibility criteria and were considered candidates for sacubitril/valsartan initiation. Of the 702 patients who did not fulfil eligibility criteria, the most common reasons were New York Heart Association functional class I (35.3%) and B‐type natriuretic peptide level of 100 pg/ml or lower (22.2%). Compared with patients in the PARADIGM‐HF trial, VAGLAHS patients were older (70.4 vs 63.8 yrs) and more likely to be male (98.5% vs 79.0%), and a higher proportion had New York Heart Association functional class III symptoms (35.4% vs 23.1%). Of the 965 patients with HFrEF, 34 (3.5%) had an active sacubitril/valsartan prescription as of November 1, 2017, of whom 27 (79.4%) did not meet criteria. Conclusion Whereas 27% of patients with HFrEF were eligible to initiate sacubitril/valsartan, only 3.5% of these patients were prescribed the medication. Although sacubitril/valsartan reduced morbidity and mortality in clinical trials, it remains underused within this VA healthcare system. This analysis provides important insights into the VA and other healthcare systems regarding the opportunity for optimizing guideline‐directed HF therapy.

Little is known about diabetes risk in adolescents and young adults with Fontan circulation. We sought to understand the prevalence of abnormal hemoglobin A1c (HgA1c) in the adolescent and young adult population with Fontan palliation. Between 2015 and 2021, 78 Fontan patients >10 years of age were seen in our single ventricle clinic; 66 underwent screening with HgA1c. 50% of the study cohort (n=33) had HgbA1c >5.7%; 2% (n=1) had HgbA1c >6.5%. There was no correlation between BMI and HgbA1c, with no difference in the prevalence of overweight or obesity (BMI >85 th percentile) between those with and without abnormal HbgA1c (31% versus 27%, p=0.69). While 20% of the cohort had a family history of diabetes, there was no difference in family history between those with and without abnormal HgbA1c (21% versus 19%, p=0.85). There were no differences in other risk factors and characteristics (race, GFR, liver function, lipid panel, hematocrit, and years from Fontan surgery) between those with and without normal HgbA1c. Our results highlight the importance of recognizing that abnormal HbA1c is highly prevalent in the Fontan population. Whether abnormal HgA1c in this population correlates with atherosclerotic cardiovascular disease in adulthood is not known. Prior studies have suggested an association among metabolic syndrome, activation of the renin-angiotensin system, chronic liver disease, chronic kidney disease, and reduced muscle mass with impaired glucose tolerance in the adult Fontan population. The mechanism for an abnormal HgA1c in the adolescent and young adult Fontan population remains unclear and further studies are needed.

Little is known about diabetes risk in adolescents and young adults with Fontan circulation. We sought to understand the prevalence of abnormal hemoglobin A1c (HgA1c) in the adolescent and young adult population with Fontan palliation. Between 2015 and 2021, 78 Fontan patients >10 years of age were seen in our single ventricle clinic; 66 underwent screening with HgA1c. 50% of the study cohort (n=33) had HgbA1c >5.7%; 2% (n=1) had HgbA1c >6.5%. There was no correlation between BMI and HgbA1c, with no difference in the prevalence of overweight or obesity (BMI >85th percentile) between those with and without abnormal HbgA1c (31% versus 27%, p=0.69). While 20% of the cohort had a family history of diabetes, there was no difference in family history between those with and without abnormal HgbA1c (21% versus 19%, p=0.85). There were no differences in other risk factors and characteristics (race, GFR, liver function, lipid panel, hematocrit, and years from Fontan surgery) between those with and without normal HgbA1c. Our results highlight the importance of recognizing that abnormal HbA1c is highly prevalent in the Fontan population. Whether abnormal HgA1c in this population correlates with atherosclerotic cardiovascular disease in adulthood is not known. Prior studies have suggested an association among metabolic syndrome, activation of the renin-angiotensin system, chronic liver disease, chronic kidney disease, and reduced muscle mass with impaired glucose tolerance in the adult Fontan population. The mechanism for an abnormal HgA1c in the adolescent and young adult Fontan population remains unclear and further studies are needed.

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