Sacubitril valsartan for chronic heart failure

This is a new guideline from NICE on when sacubitril valsartan should be used. A recent SIGN guideline gave very similar advice.

Sacubitril valsartan is a combination drug. It includes the angiotensin 2 receptor blocker (ARB), valsartan. It also includes the neprilysin inhibitor, sacubitril. Neprilysin inhibition leads to increased levels of vasoactive proteins, which leads to vasodilation. This then allows increased sodium excretion from the kidneys and so a reduced extra-cellular volume. This offloads the patient and reduces symptoms.

When can it be used?

  • Patients in NYHA categories II to IV (there is less evidence on patients in class IV) and
  • LV ejection fraction of 35% or less and
  • Who are already taking a stable dose of ACEi or ARB.
  • It should be started by a specialist.

Does it work?

The study compared it to enalapril. It showed reduced cardiovascular death and all-cause mortality. It also reduced hospitalisation for heart failure.

There are quite a lot of criticisms of the study, but NICE felt that overall there was enough evidence of benefit. If you want to read more, the Wikipedia page is quite useful.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton.

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