SAcubitril/valsartan versus ramipril in patients with ST-segment Elevation Myocardial Infarction and cardiogenic SHOCK (SAVE-SHOCK): a pilot randomized controlled trial

OBJECTIVES

To evaluate the safety and efficacy of sacubitril/valsartan versus ramipril in patients with STEMI and cardiogenic shock.

METHODS

Patients who received primary percutaneous coronary intervention (PPCI) for STEMI complicated with cardiogenic shock were randomized 1:1 to sacubitril/valsartan versus ramipril after clinical stabilization. The primary outcome was major adverse cardiac events (MACE) at 30 days and 6 months. Secondary in-hospital clinical outcomes included recurrent shock, new or re-initiation of vasoactive medications, and acute kidney injury (AKI). All-cause death, cardiac death, hospitalization due to heart failure (HF), myocardial infarction (MI), and stroke were examined at 30 days and 6 months. Study ID 016-01-2018.

RESULTS

100 patients with STEMI and cardiogenic shock were included (mean age 54.7±10.3 years, 87% men). Initiation of sacubitril/valsartan and ramipril occurred at 38.18±18.44 versus 39.0±21.03 hours after stabilization, respectively. The primary outcome was similar between both groups at 30 days and 6 months. No difference in in-hospital or 30-day clinical outcomes was observed. However, at 6 months, patients in the sacubitril/valsartan arm suffered less hospitalization with HF (18% vs 38%, P=0.044) compared with patients in the ramipril arm. Other clinical outcomes at 6 months were similar between both groups.

CONCLUSIONS

Sacubitril/valsartan in patients with STEMI and cardiogenic shock may be associated with improved clinical outcome at 6 months compared with ramipril. Larger randomized controlled trials with longer follow-up are recommended.

Diarrhoea with the angiotensin receptor neprilysin inhibitor sacubitril + valsartan: A pharmacovigilance study

Diarrhoea is an adverse drug reaction of the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril + valsartan. It was also described with olmesartan and more recently with other angiotensin receptor blockers. The study was performed to compare diarrhoea reports in pharmacovigilance databases with sacubitril + valsartan and valsartan. The study used reports of diarrhoea with the ARNI sacubitril + valsartan registered: first in the French PharmacoVigilance Database (FPVD) and second in Vigibase®, the WHO Global Individual Case Safety Report database. After description of the main characteristics, disproportionality analyses were performed. Results are reported as reporting odds ratios (ROR) with 95% confidence interval. We found 29 reports of diarrhoea with sacubitril + valsartan in the FPVD and 686 in Vigibase®. With sacubitril + valsartan, diarrhoea occurred more frequently in males around 70 years with a median delay of 3 days. With valsartan, diarrhoea occurred more frequently in females around 68 years with a median delay of 0.5 days. In the FPVD, a significant association was found with sacubitril + valsartan in comparison with valsartan alone before (ROR = 8.78 [5.19-14.85]) and after (ROR = 11.19 [5.89-21.25]) exclusion of concomitant drugs known to be associated with diarrhoea. A significant association was also found in Vigibase® after adjustment on age, sex, reporter and its location (ROR = 1.31 [1.14-1.50]). Diarrhoea reported with sacubitril + valsartan has marked differences in gender, delay of occurrence and frequency of reporting in comparison with diarrhoea with valsartan. From a pharmacodynamic point of view, these results suggest a specific role of sacubitril in diarrhoea.

Protection of kidney function and tissue integrity by pharmacologic use of natriuretic peptides and neprilysin inhibitors

With variable potencies atrial-, brain-type and c-type natriuretic peptides (NP)s, best documented for ANP and its analogues, promote sodium and water excretion, renal blood flow, lipolysis, lower blood pressure, and suppress renin and aldosterone secretion through interaction predominantly with cGMP-coupled NPR-A receptor. Infusion of especially ANP and its analogues up to 50 ng/kg/min in patients with high risk of acute kidney injury (cardiac vascular bypass surgery, intraabdominal surgery, direct kidney surgery) protects kidney function (GFR, plasma flow, medullary flow, albuminuria, renal replacement therapy, tissue injury) at short term and also long term and likely additively with the diuretic furosemide. This documents a pharmacologic potential for the pathway. Neprilysin (NEP, neutral endopeptidase) degrades NPs, in particular ANP, and angiotensin II. The drug LCZ696, a mixture of the neprilysin inhibitor sacubitril and the ANGII-AT1 receptor blocker valsartan, was FDA approved in 2015 and marketed as Entresto®. In preclinical studies of kidney injury, LCZ696 and NPs lowered plasma creatinine, countered hypoxia and oxidative stress, suppressed proinflammatory cytokines, and inhibited fibrosis. Few randomized clinical studies exist and were designed with primary cardiac outcomes. The studies showed that LCZ696/entresto stabilized and improved glomerular filtration rate in patients with chronic kidney disease. LCZ696 is safe to use concerning kidney function and stabilizes or increases GFR. In perspective, combined AT1 and neprilysin inhibition is a promising approach for long-term renal protection in addition to AT1 receptor blockers in acute kidney injury and chronic kidney disease.