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Van der Linden L, Hias J, Walgraeve K, Tournoy J, Van Aelst L, Vandenbriele C. Estimating the Time to Benefit for Therapies in Heart Failure with Reduced Ejection Fraction: A Case Study of Sacubitril-Valsartan Using Reconstructed Data from a Randomized Controlled Trial. Drugs Aging 2022; 39:959-966. [PMID: 36404386 DOI: 10.1007/s40266-022-00987-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Foundational therapies in heart failure improve clinical outcomes in heart failure with a reduced ejection fraction (HFrEF). Underuse of these life-prolonging heart failure therapies, such as sacubitril-valsartan, is common in older adults and has been associated with worse clinical outcomes. Characterizing the early benefits seen with these therapies might help increase their uptake in older adults. OBJECTIVE We applied several methods to estimate the time to benefit of an HFrEF therapy, using sacubitril-valsartan as a case study. METHODS PARADIGM-HF was a randomized controlled study on sacubitril-valsartan versus enalapril in stable, ambulatory HFrEF patients (n = 8399). The primary endpoint, a composite of death from cardiovascular causes or a first hospitalization for heart failure, was significantly reduced (sacubitril-valsartan (21.8%) versus enalapril (26.5%), hazard ratio (HR) 0.80 (95% confidence interval [CI] 0.73-0.87). We extracted and tabulated the Kaplan-Meier (KM) curves of the primary endpoint. An individual patient dataset was then reconstructed. The following methods were applied to explore the time to benefit of sacubitril-valsartan versus enalapril: visual estimation of the point of divergence of the KM curves, statistical process control (SPC), unadjusted landmark analyses using Cox proportional hazards analysis with 30-day increments until significance was persistently achieved, and comparing the survival probabilities of the extracted life tables. RESULTS Six raters visually estimated the time to benefit at a median of 60 days (interquartile range 38-10 days). Using SPC we found an early benefit from 28 days on, using the longest predefined control period of 28 days. An absolute risk reduction of 1 and 2% was found after 59 and 250 days, respectively. The reconstructed dataset provided a similar HR of 0.8004 (95% CI 0.7331-0.8739). Landmark analyses persistently showed statistical significance from 390 days and later. Survival probabilities differed from 35 days onward. CONCLUSION Using multiple approaches, the earliest benefit of sacubitril-valsartan compared to enalapril in stable HFrEF was found at about 1 month after initiation.
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Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karolien Walgraeve
- Pharmacy Department, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Public Health and Primary care, KU Leuven, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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Kim BJ, Huang CW, Chung J, Neyer JR, Liang B, Yu AS, Kwong EK, Park JS, Hung P, Sim JJ. Real-world use patterns of angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) among patients with heart failure within a large integrated health system. J Manag Care Spec Pharm 2022; 28:1173-1179. [PMID: 36125061 PMCID: PMC10372972 DOI: 10.18553/jmcp.2022.28.10.1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND: Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor (ARNI) that is now preferred in guidelines over angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) for patients with heart failure with reduced ejection fraction (HFrEF). However, it has not been broadly adopted in clinical practice. OBJECTIVE: To characterize ARNI use within a large diverse real-world population and assess for any racial disparities. METHODS: We conducted a cross-sectional study within Kaiser Permanente Southern California. Adult patients with HFrEF who received ARNIs, ACEIs, or ARBs between January 1, 2014, and November 30, 2020, were identified. The prevalence of ARNI use among the cohort and patient characteristics by ARNIs vs ACEIs/ARBs use were described. Multivariable regression was performed to estimate odds ratios and 95% CIs of receiving ARNI by race and ethnicity. RESULTS: Among 12,250 patients with HFrEF receiving ACEIs, ARBs, or ARNIs, 556 (4.54%) patients received ARNIs. ARNI use among this cohort increased from 0.02% in 2015 to 7.48% in 2020. Patients receiving ARNIs were younger (aged 62 vs 69 years) and had a lower median ejection fraction (27% vs 32%) compared with patients receiving ACEIs/ARBs. They also had higher use of mineralocorticoid antagonists (24.1% vs 19.8%) and automatic implantable cardioverterdefibrillators (17.4% vs 13.3%). There were no significant differences in rate of ARNI use by race and ethnicity. CONCLUSIONS: Within a large diverse integrated health system in Southern California, the rate of ARNI use has risen over time. Patients given ARNIs were younger with fewer comorbidities, while having worse ejection fraction. Racial minorities were no less likely to receive ARNIs compared with White patients. DISCLOSURES: Dr Huang had stock ownership in Gilead and Pfizer. Dr Liang received support for article processing and medical writing.
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Affiliation(s)
| | - Cheng-Wei Huang
- Kaiser Permanente Los Angeles Medical Center, CA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | | | | | - Brannen Liang
- University of Southern California Medical Center, Los Angeles
| | - Albert S Yu
- Kaiser Permanente Los Angeles Medical Center, CA
| | - Eric K Kwong
- Kaiser Permanente Los Angeles Medical Center, CA
| | - Joon S Park
- Kaiser Permanente Los Angeles Medical Center, CA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | - Peggy Hung
- Kaiser Permanente Los Angeles Medical Center, CA
| | - John J Sim
- Kaiser Permanente Los Angeles Medical Center, CA
- Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
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Maizels L, Wasserstrum Y, Fishman B, Segev A, Ben-Nun D, Younis A, Freimark D, Mazin I, Grupper A. Characterization of heart failure patients with reverse left ventricular remodelling post-angiotensin receptor blockers/neprilysin inhibitors therapy. ESC Heart Fail 2022; 9:1682-1688. [PMID: 35178886 PMCID: PMC9065862 DOI: 10.1002/ehf2.13801] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 12/13/2021] [Accepted: 12/18/2021] [Indexed: 11/22/2022] Open
Abstract
Aims To assess the effect of angiotensin receptor blockers/neprilysin inhibitors (ARNI) on left ventricular (LV) ejection fraction (LVEF) and LV dimensions in a real‐life cohort of heart failure and reduced ejection fraction (HFrEF) patients, while analysing patient characteristics that may predict reverse LV remodelling. Methods and results The ARNI‐treated HFrEF patients followed at a single tertiary medical centre HF‐outpatient clinic were included in the study. Clinical and echocardiographic parameters were evaluated prior to ARNI initiation, and while on ARNI therapy, assessing patient characteristics associated with reverse LV remodelling. The cohort included 91 patients (mean age 60.5 years, 90% male) and 47 (52%) patients exhibited ARNI responsiveness, defined as an increase in LVEF during therapy. Overall, LVEF increased by 19% post‐ARNI (23.8 to 28.4%, P < 0.001). Subgroup analysis revealed several parameters associated with significant LVEF improvement, including baseline LVEF <30%, non‐ischaemic HF aetiology, lack of cardiac resynchronization therapy (CRT), better initial functional class and ARNI initiation within 3 years from HF diagnosis (P ≤ 0.001 for all). Significant reduction in LV dimensions was noted in patients with lower initial LVEF, non‐ischaemic HF and no CRT. Further combined subgrouping of the study population demonstrated that patients with both LVEF <30% and a non‐ischaemic HF gained most benefit from ARNI with an average of 51% improvement in LVEF (19.9 to 30%, P < 0.001). Conclusions The ARNI treatment response is not uniform among HFrEF patient subgroups. More pronounce reverse LV remodelling is associated with early ARNI treatment initiation in the course of HFrEF, and in those with LVEF <30%, non‐ischaemic HF and no CRT.
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Affiliation(s)
- Leonid Maizels
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-HaShomer, Sheba Rd. 2, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Talpiot Sheba Medical Leadership Program, Tel-Aviv, Israel
| | - Yishay Wasserstrum
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-HaShomer, Sheba Rd. 2, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Boris Fishman
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-HaShomer, Sheba Rd. 2, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,The Talpiot Sheba Medical Leadership Program, Tel-Aviv, Israel
| | - Amitai Segev
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-HaShomer, Sheba Rd. 2, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - David Ben-Nun
- The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anan Younis
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-HaShomer, Sheba Rd. 2, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dov Freimark
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-HaShomer, Sheba Rd. 2, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Israel Mazin
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-HaShomer, Sheba Rd. 2, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Avishay Grupper
- Division of Cardiology, Leviev Center of Cardiovascular medicine, Sheba Medical Center in Tel-HaShomer, Sheba Rd. 2, Ramat-Gan, Israel.,The Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Zhang R, Sun X, Li Y, He W, Zhu H, Liu B, Zhang A. The Efficacy and Safety of Sacubitril/Valsartan in Heart Failure Patients: A Review. J Cardiovasc Pharmacol Ther 2022; 27:10742484211058681. [PMID: 34994233 DOI: 10.1177/10742484211058681] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) is one of the leading causes of morbidity and mortality worldwide. Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor, has been approved for the treatment of HF. At present, there have been few systematic and detailed reviews discussing the efficacy and safety of sacubitril/valsartan in HF. In this review, we first introduced the pharmacological mechanisms of sacubitril/valsartan, including the reduction in the degradation of natriuretic peptides in the natriuretic peptide system and inhibition of the renin-angiotensin system. Then, we summarized the efficacy of sacubitril/valsartan in HF patients with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF) including the reduction in risks of mortality and hospitalization, reversal of cardiac remodeling, regulation of biomarkers of HF, improvement of the quality of life, antiarrhythmia, improving renal dysfunction and regulation of metabolism. Finally, we discussed the safety and tolerability of sacubitril/valsartan in the treatment of HFrEF or HFpEF. Compared with ACEIs/ARBs or placebo, sacubitril/valsartan showed good safety and tolerability, although the risk of hypotension might be high. In conclusion, the overwhelming majority of studies show that sacubitril/valsartan is effective and safe in the treatment of HFrEF patients but that it has little benefit in HFpEF patients. Sacubitril/valsartan will probably be a promising anti-HF drug in the near future.
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Affiliation(s)
- Rui Zhang
- Department of Cardiology, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Care Unit, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Rehabilitation Centre, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Xiaotong Sun
- Shandong Provincial Medicine and Health Key Laboratory of Clinical Anesthesia, Department of Anesthesiology, Weifang Medical University, Weifang, China
| | - Ya Li
- Department of Cardiology, Shanghai General Hospital, School of Medicine, 12474Shanghai Jiaotong University, Hongkou District, Shanghai, China
| | - Wenzheng He
- Intensive Care Unit, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Hongguang Zhu
- Dental Department, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Baoshan Liu
- Department of Cardiology, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Care Unit, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Rehabilitation Centre, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Aiyuan Zhang
- Department of Cardiology, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Care Unit, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Rehabilitation Centre, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
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Angiotensin Receptor-Neprilysin Inhibitor (ARNI) and Cardiac Arrhythmias. Int J Mol Sci 2021; 22:ijms22168994. [PMID: 34445698 PMCID: PMC8396594 DOI: 10.3390/ijms22168994] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/17/2021] [Accepted: 08/19/2021] [Indexed: 12/11/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) plays a major role in cardiovascular health and disease. Short-term RAAS activation controls water and salt retention and causes vasoconstriction, which are beneficial for maintaining cardiac output in low blood pressure and early stage heart failure. However, prolonged RAAS activation is detrimental, leading to structural remodeling and cardiac dysfunction. Natriuretic peptides (NPs) are activated to counterbalance the effect of RAAS and sympathetic nervous system by facilitating water and salt excretion and causing vasodilation. Neprilysin is a major NP-degrading enzyme that degrades multiple vaso-modulatory substances. Although the inhibition of neprilysin alone is not sufficient to counterbalance RAAS activation in cardiovascular diseases (e.g., hypertension and heart failure), a combination of angiotensin receptor blocker and neprilysin inhibitor (ARNI) was highly effective in several clinical trials and may modulate the risk of atrial and ventricular arrhythmias. This review summarizes the possible link between ARNI and cardiac arrhythmias and discusses potential underlying mechanisms, providing novel insights about the therapeutic role and safety profile of ARNI in the cardiovascular system.
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Thomas M, Khariton Y, Fonarow GC, Arnold SV, Hill L, Nassif ME, Chan PS, Butler J, Thomas L, DeVore AD, Hernandez AF, Albert NM, Patterson JH, Williams FB, Spertus JA. Association between sacubitril/valsartan initiation and real-world health status trajectories over 18 months in heart failure with reduced ejection fraction. ESC Heart Fail 2021; 8:2670-2678. [PMID: 33932120 PMCID: PMC8318450 DOI: 10.1002/ehf2.13298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/09/2021] [Accepted: 02/24/2021] [Indexed: 12/11/2022] Open
Abstract
Aims Improving the health status (symptoms, function, and quality of life) of patients with heart failure with reduced ejection fraction (HFrEF) is a primary treatment goal. Angiotensin receptor neprilysin inhibitors (ARNI) improve short‐term health status in clinical practice, but the sustainability of these improvements is unknown. Methods and results In CHAMP‐HF, a multicentre observational study of outpatients with HFrEF, patients initiated on ARNI were propensity score matched 1:2 to patients not using ARNI with Cox regression modelling time to ARNI initiation, adjusted for sociodemographic and clinical variables, medical history, medications, and baseline Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. Repeated measures models for the overall KCCQ score and each domain compared the health status trajectories of patients initiated on ARNI vs. not. Among 3930 participants, 746 (19.0%) began ARNI, of whom 576 were matched to 1152 non‐ARNI patients. Prior to matching, participants initiated on ARNI were younger, non‐Hispanic, had lower EFs, more commonly had a history of ventricular arrhythmia, were less likely to be taking an ACEI/ARB, and more likely to be treated with beta‐blockers and mineralocorticoid receptor antagonists. There were no differences after matching. In the matched cohort, participants initiated on ARNI experienced improved health status by 3 months that persisted through 12 months [KCCQ Overall Summary Score (OSS) = 73.4 vs. 70.8; P < 0.001], with the largest benefit observed in the KCCQ Quality of Life domain (68.7 vs. 64.7; P < 0.001). Similar health status benefits were noted through 18 months (KCCQ‐OSS = 73.9 vs. 71.3; P < 0.001). A responder analysis showed that 12 patients would need to be initiated on ARNI for one to experience at least a large improvement (≥10 points) in health status benefit at 12 months. Conclusions In outpatient practice, ARNI therapy was associated with improved health status by 3 months and continued to 18 months after initiating therapy.
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Affiliation(s)
- Merrill Thomas
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Yevgeniy Khariton
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Larry Hill
- Duke Clinical Research Institute, Durham, NC, USA
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Department of Medicine, and the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Department of Medicine, and the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
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