Haemodynamic effects of sacubitril/valsartan in advanced heart failure

Abstract

AimsThe angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril/valsartan, has been shown to be effective in treatment of patients with heart failure (HF), but limited data are available in patients with advanced disease. This retrospective observational study assessed the effects of ARNI treatment in patients with advanced HF. Methods and resultsWe reviewed medical records of all advanced HF patients evaluated at our centre for unconventional therapies from September 2016 to January 2019. We studied 44 patients who started ARNI therapy and who had a haemodynamic assessment before beginning ARNI and after 6 ± 2 months. The primary endpoint was variation in pulmonary pressures and filling pressures at 6 months after starting ARNI therapy. Mean patient age was 51.6 ± 7.4 years; 84% were male. At 6 ± 2 months after starting ARNI, there was significant reduction of systolic pulmonary artery pressure [32 mmHg, interquartile range (IQR) 27-45 vs. 25 mmHg, IQR 22.3-36.5; P < 0.0001] and mean pulmonary artery pressure (20 mmHg, IQR 15.3-29.8 vs. 17 mmHg, IQR 13-24.8; P = 0.046). Five of 22 patients (23%) were deferred from the heart transplant list because of improvement, whereas four were listed de novo. After 23 ± 9 months, three patients were treated with a left ventricular assist device implantation, whereas six patients underwent heart transplantation (one in emergency conditions for refractory ventricular tachycardia). Conclusions Sacubitril/valsartan is effective in reducing filling pressures and pulmonary pressures in patients with advanced HF. The absence of adverse events during follow-up suggests that sacubitril/valsartan is safe and well-tolerated in this cohort of patients.

A Importância Da Abordagem Clínica E Terapêutica Para Manejo E Tratamento Da Insuficiência Cardíaca Avançada

“…A terapia crônica de pacientes sintomáticos de IC pode ser melhorada com a dependência de medicamentos que favorecem a remodelação cardíaca e a hemodinâmica. Sacubitril/valsartana, por exemplo, demonstrou reduzir o enchimento e as pressões pulmonares também em pacientes com disfunção cardíaca grave 13 . A redução da pressão de cunha do ventrículo esquerdo está documentada após a introdução do SGLT2i no tratamento da IC 14 .…”

Heart Failure Management through Telehealth: Expanding Care and Connecting Hearts

“…No clinical experience regarding using a remote monitor in the "bridge to transplantation" strategy has been described. Yet, clinical trials have demonstrated a net reduction in pulmonary artery pressures with the titration of medical therapies in a population with features similar to the HTx candidates (NYHA class III or IV, recurrent hospitalizations, and high natriuretic peptides values regardless of optimal medical therapy), implying a possible role of these devices in a high-risk population, where monitoring the pulmonary pressure trend could be valuable in identifying the optimal HT "window" [86][87][88]. An intriguing application for these devices could regard patients undergoing periodic or continuous inotropic therapy, where hemodynamic data might provide crucial insights to optimize therapeutic management [89].…”

Advanced heart failure: from definitions to therapeutic options

“…Sacubitril/valsartan, for example, has been shown to reduce filling and pulmonary pressures also in patients with severe cardiac dysfunction. 6 Left ventricular wedge pressure reduction is documented after introducing SGLT2i in HF treatment. 7 The main feature prevailing in patients with AHF (stage D of the AHA/ACC classification) is the reduction of SV, often accompanied by further LV dilatation, features progressing with the continuum of the disease and frequently associated with mitral regurgitation, which exacerbates the volume overload, ventricle dilatation, and reduction on SV.…”