Beneficial Acute Hemodynamic Effects of Sacubitril-Valsartan in Patients with Low-Cardiac Output Including Significant Improvement in PAPi

Abstract

PIONEER-HF established the safety of the angiotensin receptor-neprilysin inhibitor (ARNI), sacubitril-valsartan (S/V), in patients hospitalized with acute decompensated heart failure after achieving hemodynamic stability. We have previously shown that transitioning patients in cardiogenic shock directly from intravenous (IV) vasoactive (i.e. vasodilators or inotropes) drugs to S/V can be done safely with tolerance to one-month follow-up. Here we further characterize the hemodynamic impact of S/V after patients have been optimized on vasoactive therapy. A single-center, retrospective analysis of all patients with HFrEF (EF <40%) who had been newly initiated on S/V in the cardiac intensive care units (CICUs) was performed. Hemodynamic data was gathered on CICU admission, on vasoactive therapy, and post S/V initiation. Statistical analyses used paired t-tests (SAS, version 9.4). Twenty-two patients with HFreF and cardiac index below 2.2 L/min/m2 were admitted to the CICU and newly initiated on S/V. Table 1a contains baseline characteristics and vasoactive therapy given. All patients were weaned off vasoactive medications prior to transfer out of CICU. Patients maintained their significant hemodynamic improvement on transition from IV to oral vasoactive therapy. There was an increase in Pulmonary Artery Pulsatility index (PAPi) with S/V therapy (Table 1b). Patients who did not tolerate ARNI initiation had lower filling pressures and systolic blood pressure compared to patients who tolerated ARNI initiation. Seventeen patients were discharged home on S/V, and 94% remained on S/V one-month in follow-up. ICU patients can be successfully bridged from vasoactive IV therapy to oral S/V with sustained hemodynamic improvement garnered from vasoactive agents. We also observed improvement in PAPi with S/V compared to both admission and vasoactive therapy. These encouraging findings merit further prospective study.