Sacubitril-valsartan Versus Usual Anti-hypertensives in LVAD

Study Overview
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Brief Summary
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This pilot, feasibility study evaluates the efficacy of sacubitril-valsartan (Entresto) versus usual anti-hypertensive medications in patients with left ventricular assist devices (LVAD). It also measures diurnal blood pressure variations in the context of continuous flow physiology.

Detailed Description
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Left ventricular assist devices (LVAD) have become a life-saving therapy for patients with ACC/AHA stage D congestive heart failure (CHF). Despite longevity and improved quality of life, LVAD-supported patients are plagued with adverse events, the most debilitating of all is stroke. Ischemic and hemorrhagic strokes have been associated with hypertension (mean arterial pressure, or MAP > 90 mmHg) in addition to out-of-range INR and aspirin doses. Strict blood pressure control has been shown in a recent randomized trial to confer a significant decline in stroke rates of patients implanted with the Heartware LVAD. Patients with poorly controlled hypertension are also at risk for inadequate left-ventricular unloading and worsening CHF due to the exquisite sensitivity to afterload of the continuous flow LVAD. There are no guidelines for the use of anti-hypertensives in LVAD patients. Most are started on standard CHF therapies, though this practice varies greatly across LVAD centers. The angiotensin receptor blocker-neprilysin inhibitor sacubitril-valsartan (Entresto) is a potent anti-hypertensive mediation that was recently approved by the Food and Drug Administration for the treatment of patients with heart failure and low ejection fraction. We aim to randomly assign patients to receive Entresto or usual anti-hypertensive therapy for blood pressure control, then crossover to the other arm after 30 days. Daily blood pressure measurements will be performed and correlated with LVAD pump flows and waveform analysis.

Official Title
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Sacubitril-valsartan (Entresto) Versus Standard Anti-hypertensive Therapy in LVAD Patients - A Feasibility Pilot Study

Conditions
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Congestive Heart Failure, Hypertension

Intervention / Treatment
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* Drug: Entresto
* Drug: Valsartan


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: More than 30 days after LVAD implant Ambulatory MAP > 85 mmHg requiring initiation of anti-hypertensive medications Exclusion Criteria: Allergy to ACEI or ARB eGFR < 30 mL/min/1.73m2 K > 5.4 mmol/L MAP < 60 Inability to check blood pressure at home Lack of prescription coverage Frequent hospitalizations (monthly)

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Entresto<br>First-line anti-hypertensive: sacubitril-valsartan, starting at 24-26 mg twice daily, increasing to maximum dose of 97-103 mg twice daily | Drug: Entresto<br>* First line therapy in Entresto arm<br>Drug: Valsartan<br>* First line therapy in usual meds arm<br>|
| Active Comparator: Usual meds<br>First-line anti-hypertensive: valsartan, starting at 40 mg twice daily, increasing to a maximum dose of 160 mg twice daily | Drug: Entresto<br>* First line therapy in Entresto arm<br>Drug: Valsartan<br>* First line therapy in usual meds arm<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time spent with MAP < 85 mmHg | Daily mean arterial pressure (MAP) < 85 mmHg | 2 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of drugs | Number of anti-hypertensive drugs needed to achieve MAP < 85 mmHg | 2 months | 
| Pump flow | Correlation of pump flow with daily MAP | 2 months |