Heart Failure Newer Tx

Question 1

Angiotensin ReceptorNeprilysin Inhibitor (ARNI)

Answer 1

• Sacubitril + valsartan (Entresto®)
• Sacubitril = neprilysin inhibitor
• Neprilysin: major enzyme breaking down natriuretic peptides (NP)
• BNP secreted by ventricles, elevated in HF

Question 2

Angiotensin ReceptorNeprilysin Inhibitor (ARNI)

Answer 2

• Indication:
– Patients with HFrEF and NYHA FC II -III, to
decrease the incidence of CV death and HF
hosp (in place of ACEI/ARB

Question 3

Angiotensin ReceptorNeprilysin Inhibitor (ARNI)
switching agents
dose range

Answer 3

• Switching agents:
– Prior ACEI: stop ACEI and wait at least 36 hr after
last dose; ↑ risk of angioedema
• Dose range:
– 50 mg bid: RAAS naïve/low dose RAAS inhib, risk for
hypotension: poor renal function, low baseline BP
– 100mg bid titrate (q3-6wks) to 200mg bid
– Dose is sum of both agents eg. 200mg tablet =
97/103mg
• Valsartan component:
– Note different valsartan salts
– Entresto® = 103mg, Diovan® = 160mg

Question 4

Angiotensin Receptor Neprilysin Inhibitor (ARNI)
monitoring
cost

Answer 4

• Monitoring:
– as per ACEI/ARB (hyperkalemia, renal function)
– increase symptomatic hypotension (ARI 4.8%,
NNH 21), angioedema (rare in both groups).
- consider reducing diuretic dosage (euvolemic,
symptomatic hypotension, SGLT2 inhib)
• Cost:
– Special authorization for ABC coverage (& by
specialist)
– Cost: $257/mos (enalapril $28/mos)

Question 5

Angiotensin ReceptorNeprilysin Inhibitor (ARNI)

Place in therapy

Answer 5

Recommended in patients with:
• chronic HFrEF (ambulatory)
• AHF: switch from ACE/ARB when
stabilized, prior to discharge
• new Dx of HFrEF, suggest start ARNI
rather than ACE/ARB