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Table of Contents
LETTER TO THE EDITOR
Year : 2021  |  Volume : 9  |  Issue : 4  |  Page : 274-275

Role of ARNI upgraded in treatment of heart failure with reduced ejection fraction


Highborn Poly Clinic, Gulbarga, Karnataka, India

Date of Submission21-May-2021
Date of Decision27-Jun-2021
Date of Acceptance29-Jul-2021
Date of Web Publication20-Oct-2021

Correspondence Address:
Dr. Swetha Amaresh Biradar
Flat Number 5 Third Floor Sharandeep Apartment, Doctors Colony, Jaya Nagar, Sedam Road, Kalaburagi - 585 105, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajim.ajim_53_21

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How to cite this article:
Biradar SA. Role of ARNI upgraded in treatment of heart failure with reduced ejection fraction. APIK J Int Med 2021;9:274-5

How to cite this URL:
Biradar SA. Role of ARNI upgraded in treatment of heart failure with reduced ejection fraction. APIK J Int Med [serial online] 2021 [cited 2021 Nov 29];9:274-5. Available from: https://www.ajim.in/text.asp?2021/9/4/274/328677



In 2017, ACC/AHA recommended in patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACEI or ARB, replacement by an ARNI was recommended to further reduce morbidity and mortality.[1]

Clinical practice update on heart failure by ESC in 2019 recommended Sacubitril/valsartan as a replacement for ACE-I/ARBs to reduce the risk of HF hospitalization and death in ambulatory patients with HFrEF who remain symptomatic despite optimal medical treatment with an ACE-I, a beta-blocker and a MRA.[2] Initiation of sacubitril/valsartan rather than an ACE-I or an ARB may be considered for patients hospitalized with new-onset HF or decompensated CHF to reduce the short-term risk of adverse events and to simplify management (by avoiding the need to titrate ACE-I first and then switch to sacubitril/valsartan). Because these patients are already at high risk of events, there is no need to check plasma concentrations of natriuretic peptides prior to initiating sacubitril/valsartan. As indicated in the 2016 HF guidelines,[3] ambulatory patients with HFrEF should have an elevated plasma concentration of natriuretic peptides indicating increased risk and the need for more effective therapy.

2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment for patients with newly diagnosed stage C heart failure with reduced ejection fraction (HFrEF) a beta blocker and an angiotensin converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI) should be started in any order.[4] Each agent should be up-titrated to maximally tolerated or target dose. The initiation of a beta blocker is better tolerated when a patient is dry and an ACEI/ARB/ARNI when patients are wet.

In HFrEF, patients ARNI was initially used as switch therapy from ACEI/ARBs. However, the accumulation of new evidence ARNI can be used as first line instead of ACEI/ARBS with recent ACC/AHA recommendations published in JACC 2021.

The recently presented PARADISE MI trial showed that ARNI did not reduce the primary end point in AMI population compared with Ramipril. The primary outcome of CV death, first HF hospitalization, or outpatient HF for ARNI versus Ramipril was 11.9% versus 13.2% 9p = 0.17. Combination of sacubitril/valsartan did not reduce the primary end point in a contemporary AMI population compared with Ramipril.[5],[6]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr., Colvin MM, et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2017;136:e137-61.  Back to cited text no. 1
    
2.
Seferovic PM, Ponikowski P, Anker SD, Bauersachs J, Chioncel O, Cleland JG, et al. Clinical practice update on heart failure 2019: Pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019;21:1169-86.  Back to cited text no. 2
    
3.
Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail 2016;18:891-975.  Back to cited text no. 3
    
4.
Writing Committee, Maddox TM, Januzzi JL Jr, Allen LA, Breathett K, Butler J, et al. 2021 Update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction: A report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021;77:772-810.  Back to cited text no. 4
    
5.
Jering KS, Claggett B, Pfeffer MA, Granger C, Køber L, Lewis EF, et al. Prospective ARNI vs. ACE inhibitor trial to DetermIne Superiority in reducing heart failure Events after Myocardial Infarction (PARADISE-MI): Design and baseline characteristics. Eur J Heart Fail 2021;23:1040-8.  Back to cited text no. 5
    
6.
Presented by Dr Marc Pfeffer at the American college of Cardiology Virtual Annual Scientific Session (ACC2021), May 15, 2021.  Back to cited text no. 6
    




 

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