Introduction:

Sacubitril/valsartan is an angiotensin-receptor neprilysin Inhibitor (ARNI) that reduced the risk of death or hospitalization for heart failure vs enalapril in the PARADIGM-HF trial. Sacubitril/valsartan increases natriuresis and diuresis by inhibiting the breakdown of vasoactive peptides. In a post-hoc analysis of the PARADIGM-HF trial, patients on sacubitril-valsartan had overall decreased diuretic use compared to patients on enalapril. This study tests this hypothesis in a real-world population of heart failure patients.

Research Question:

This study compared the absolute change in loop diuretic dose at 6 months between patients started on sacubitril/valsartan and similar patients who started or increased their dose of ACE-I or ARB within the University of Utah Heart Failure and Recovery Clinic between January 1, 2016 and December 31, 2018.

Study Design:

Retrospective cohort study.

Methods:

Patients 18 to 89 years prescribed sacubitril/valsartan or who started/increased their dose of ACEi or ARB, with left ventricular ejection fraction ≤40%, and who are seen in the University of Utah Heart Failure and Recovery Clinic were identified via Epic Hyperspace Reports and reviewed for inclusion. If the sacubitril-valsartan, ACEi, or ARB was discontinued or the patient received a heart transplant or left ventricular assist device during the 6 month period, the patient was excluded. Loop diuretic doses at 0 and 6 months, and other patient characteristics were obtained via chart review. The primary endpoint is absolute change in loop dose. Secondary endpoints are percent of patients needing a loop dose increase and percent needing a decrease. The primary outcome was analyzed using a t-test (if the data are normally distributed or a non-parametric test if not).

Results:

Preliminary data showed the change in loop diuretic dose for the ACEi/ARB group was 12.35 and for the sacubitril/valsartan group was -2.1 (p=0.077) this does not meet statistical significance between groups. However, only 10.29% of sacubitril/valsartan required a dose increase, compared to 33.34% in the ACEi/ARB group (p=0.028). There was no difference in percent needing a loop diuretic dose decrease.

Conclusion:

Per preliminary results sacubitril/valsartan does not have a statistically significant net reduction in loop diuretic dose compared to the ACEi/ARB group. Sacubitril/valsartan required less of a loop diuretic dose increase compared to the ACEi/ARB group. More information is necessary to determine sacubitril/valsartan’s effect on loop diuretic dose.