Effect of Treatment With Sacubitril/Valsartan in Patients With Advanced Heart Failure and Reduced Ejection Fraction
Authors: Douglas L. Mann, Michael M. Givertz, Justin M. Vader, Randall C. Starling, Palak Shah, Steven E. McNulty, Kevin J. Anstrom, Kenneth B. Margulies, Michael S. Kiernan, Claudius Mahr, Divya Gupta, Margaret M. Redfield, Anuradha Lala, Gregory D. Lewis, Adam D. DeVore, Patrice Desvigne-Nickens, Adrian F. Hernandez, Eugene Braunwald, Selma F. Mohammed, Hellina Birru, Etsubdink Aboye, Phillip H. Lam, Nicole Escobar, Maria Fink, Thomas P. Cappola, Wendy Sheaffer, Bonitta Reilly, Jenny Ferree, Ashwin K. Ravichandran, Gina Ciezkowski, Glenda Herrera, Hirsch S. Mehta, Rosemarie DeLucca, Sanjay Doddamani, Manreet Kanwar, Brooke Thomas, Laurie Machen, January Kim, Athas Christina, Brent C. Lampert, Cindy Fontenelle, Clement C. Eiswirth, Julie Williams, Darlene Rock, Gregory F. Egnaczyk, Enya Rentas-Sherman, Deborah Barr, Arvind Bhimaraj, Adrianna Damato, Christine Calayo, John M. Herre, Joann Lindenfeld, Amanda Carroll, Mary Gordon, Mary E. Keebler, Bandaa Setliff, Sanjeev K. Gulati, Krystal Winkler, Laura Curtin, Carly Ohmart, John Halvorson, James O. Mudd, S. Albert Camacho, Maryse Palardy, Neha Shah, Kristina Picardi, Arun Krishnamoorthy, Adrienne Maximin, Douglas A. Horstmanshof, Beverly Seiler, Zi J. Xu, Savannah Mersola, Evan P. Kransdorf, Wilson Tang, Teresa Fonk, Eiran Z. Gorodeski, Guilherme H. Oliveira, Terrence Semenec, Nadine Norton, Julie Nichols, Peter Leo, Mark E. Dunlap, G. Michael Felker, Lacey Taylor, Mary Sheehan, Sharon Levine, Diane Cocca-Spofford, Liana Brooks, Thomas Cunningham, Nancy Acker, Susan Milbrandt, Janet Gatzke, Victor G. Davila-Roman, Anne Dirks, Karen Bult, Elizabeth Weber, Mary Lesko, Deana Mikhalkova, Kathleen Fitzgerald, David J. Whellan, Omar Wever-Pinzon, Jonathan Gutierrez, Yavette Goldsborough, Nisha A. Gilotra, Indre Caikauskaite, Hal A. Skopicki, Gordon S. Huggins, Nathan Yuen, Abbey Haynes, Carr Katie, Gail Snell, Andrew L. Smith, Brandon Walker, Jovita Johnson, Simmone Henderson, Sunil Pauwaa, Geetha Bhat, Ann Gagliardi
Journal: JAMA Cardiology (2021)

<h3>Importance</h3> The use of sacubitril/valsartan is not endorsed by practice guidelines for use in patients with New York Heart Association class IV heart failure with a reduced ejection fraction because of limited clinical experience in this population. <h3>Objective</h3> To compare treatment with sacubitril/valsartan treatment with valsartan in patients with advanced heart failure and a reduced ejection fraction and recent New York Heart Association class IV symptoms. <h3>Design, Setting, and Participants</h3> A double-blind randomized clinical trial was conducted; a total of 335 patients with advanced heart failure were included. The trial began on March 2, 2017, and was stopped early on March 23, 2020, owing to COVID-19 risk. <h3>Intervention</h3> Patients were randomized to receive sacubitril/valsartan (target dose, 200 mg twice daily) or valsartan (target dose, 160 mg twice daily) in addition to recommended therapy. <h3>Main Outcomes and Measures</h3> The area under the curve (AUC) for the ratio of N-terminal pro–brain natriuretic peptide (NT-proBNP) compared with baseline measured through 24 weeks of therapy. <h3>Results</h3> Of the 335 patients included in the analysis, 245 were men (73%); mean (SD) age was 59.4 (13.5) years. Seventy-two eligible patients (18%) were not able to tolerate sacubitril/valsartan, 100 mg/d, during the short run-in period, and 49 patients (29%) discontinued sacubitril/valsartan during the 24 weeks of the trial. The median NT-proBNP AUC for the valsartan treatment arm (n = 168) was 1.19 (IQR, 0.91-1.64), whereas the AUC for the sacubitril/valsartan treatment arm (n = 167) was 1.08 (IQR, 0.75-1.60). The estimated ratio of change in the NT-proBNP AUC was 0.95 (95% CI 0.84-1.08;<i>P</i> = .45). Compared with valsartan, treatment with sacubitril/valsartan did not improve the clinical composite of number of days alive, out of hospital, and free from heart failure events. Aside from a statistically significant increase in non–life-threatening hyperkalemia in the sacubitril/valsartan arm (28 [17%] vs 15 [9%];<i>P</i> = .04), there were no observed safety concerns. <h3>Conclusions and Relevance</h3> The findings of this trial showed that, in patients with chronic advanced heart failure with a reduced ejection fraction, there was no statistically significant difference between sacubitril/valsartan and valsartan with respect to reducing NT-proBNP levels. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT02816736