Important Strategies in Initiating Sacubitril

Valsartan for HFrEF Patients:

What is the Guidance?

Erwinanto MD
Department of Cardiology and Vascular Medicine
Division of Cardiovascular, Department of Internal Medicine
Faculty of Medicine Universitas Padjadjaran
Dr. Hasan Sadikin General Hospital
Bandung
PATIENTS NEED NEW

TREATMENT
Ponikowski P, et al. Eur Heart J 2016 doi:10.1093/eurheartj/ehw128
 DOCTORS OFTEN SAY:

No need to change heart failure medications because

• My patient has “MILD” symptom

• My patient is “STABLE”

• My patient is on “OPTIMAL MEDICATIONS”

Clinical or therapeutic inertia is defined as

the lack of treatment initiation or the

intensification of therapies on par with

evidence-based published clinical

guidelines to achieve therapeutic goals.

Lebeau J-P, et al. BMC Fam Pract 2014;15:130.

Patients with the same level of functional capacity can

report different daily functioning, symptoms, and

quality of life.

Am Heart J 2012;163:88-94
ACE-I 100%
Beta-blocker 93%
MRA 57%

69% NYHA II
25% NYHA III

Packer M, et al. Circulation 2015;131:54-61

 Death from cardiovascular causes

1.0
ACE-I 100%
Cumulative probability

0.6 Beta-blocker 93%

0.5
MRA 57%
0.4 69% NYHA II
0.3
25% NYHA III
0.2

0.1

0.0
0 180 360 540 720 900 1080 1260

Days from randomization

McMurray JJV, et al. N Engl J Med 2014;371:993-1004.

GUIDELINE DIRECTED

MEDICAL TREATMENT
Ponikowski P, et al. Eur Heart J 2016 doi:10.1093/eurheartj/ehw128
Ponikowski P, et al. Eur Heart J 2016 doi:10.1093/eurheartj/ehw128
Ponikowski P, et al. Eur Heart J 2016 doi:10.1093/eurheartj/ehw128
Ponikowski P, et al. Eur Heart J 2016 doi:10.1093/eurheartj/ehw128
Ponikowski P, et al. Eur Heart J 2016 doi:10.1093/eurheartj/ehw128
Ponikowski P, et al. Eur Heart J 2016 doi:10.1093/eurheartj/ehw128
BENEFITS OF ADDING

SACUBITRIL VALSARTAN
 IMPORTANT GUIDANCE IN

INITIATING AND MAINTAINING

SACUBITRIL VALSARTAN
1. Follow guideline directed treatment algorithm.

2. Patients need to tolerate ACE-I or ARB.

3. Combined treatment with ACE-I or ARB is not

allowed.

4. Stop ACE-I for at least 36 h before initiating ARNI.

5. Start only when SBP ≥100 mm Hg.

6. Initiation dose 49/51 mg twice daily.

7. Titrates dose to 97/103 mg in 4-6 weeks.

8. Careful BP observation is mandatory.

TAKE-HOME MESSAGE
Sacubitril valsartan is indicated to replace ACE-I in

patients with HFrEF who:

• Have EF ≤35%

• Still symptomatic (NYHA class II-IV) despite

treatment with an ACE-I (or ARB), a beta-blocker,

and an MRA at the highest tolerated dose

• Stop ACE-I for at least 36 h before initiating

sarcubitril valsartan.

• Start only when SBP ≥100 mm Hg.

• Initiation dose 49/51 mg twice daily.

• Titrates dose to 97/103 mg in 4-6 weeks.

• Careful BP observation is mandatory.