Sacubitril/valsartan in everyday clinical practice: an observational study based on the experience of a heart failure clinic.

Background: Heart failure (HF) is a growing public health problem. Sacubitril/valsartan is now recommended to be used in persistently symptomatic patients with left ventricular ejection fraction (LVEF) <40%, replacing angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs). In the present study, we aimed to characterise the challenges of sacubitril/valsartan use in everyday clinical practice.
Methods: We assessed the medical records of patients with HF and reduced ejection fraction eligible for sacubitril/valsartan attending a HF clinic at a Portuguese University Hospital during 2018 (n=152). The number of eligible patients receiving the drug and the reasons for not prescribing sacubitril/valsartan were evaluated. Additionally, we assessed the tolerability of maximal doses of sacubitril/valsartan. New York Heart Association functional class (NYHA class) and LVEF before and after up-titration to maximal tolerated sacubitril/valsartan dose were compared. Median follow-up was 41 months.
Results: Of the 152 included patients, 75 (49%) were prescribed the drug. The two main reasons for non-prescription were patient financial barriers (31%) and hypotension (27%). Only 33% of patients on sacubitril/valsartan did reach maximal dose. Hypotension was the main limiting factor for dose optimisation. Duration of sacubitril/valsartan treatment showed a positive association with LVEF improvement during follow-up (6.6% absolute LVEF increase/year). NYHA functional class improved significantly from baseline through the end of follow-up.
Conclusions: In every-day clinical practice, although sacubitril/valsartan was associated with a marked improvement in NYHA class and in LVEF, important financial and clinical barriers to the implementation of this therapy were identified.
Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/cdt-21-312). All authors report that this work was supported by Novartis, via funding for third-party medical writing, review, and submission of this manuscript. AS has received speaker fees or advisory board participation fees from MSD, Merck Serono, Novartis, Servier, Bial and Pfizer outside of this work. BM has received speaker fees from AstraZeneca, Boehringer Ingelheim, Lilly, Servier, Novartis and Merck Serono outside of this work. JSC has received speaker and consultant fees, or advisory board participation fees from Abbott, AstraZeneca Pharmaceuticals, Bial, Boehringer Ingelheim, Menarini, Merck Serono, Merck Sharp & Dohme, Novartis, Orion, Pfizer, Sanofi, Servier, and Vifor Pharma outside of this work. The authors have no other conflicts of interest to declare.
(2021 Cardiovascular Diagnosis and Therapy. All rights reserved.)