Abstract
Background: The effect of sacubitril/valsartan on survival and hospitalization risk in older patients with heart failure has not been explored. We aimed to investigate the risk of hospitalization and mortality with the use of sacubitril/valsartan vs. enalapril in patients with heart failure.Methods: This was a population-based cohort study using the Hong Kong-wide electronic healthcare database. Patients diagnosed with heart failure and newly prescribed sacubitril/valsartan or enalapril between July 2016 and June 2019 were included. The risk of primary composite outcome of cardiovascular mortality or heart failure-related hospitalization, all-cause hospitalization, heart failure-related hospitalization, cardiovascular mortality and all-cause mortality were compared using Cox regression with inverse probability treatment weighting. Additional analysis was conducted by age stratification.Results: Of the 44,503 patients who received sacubitril/valsartan or enalapril, 3,237 new users (sacubitril/valsartan, n = 1,056; enalapril, n = 2,181) with a diagnosis of heart failure were identified. Compared with enalapril, sacubitril/valsartan users were associated with a lower risk of primary composite outcome [hazard ratio (HR) 0.58; 95% confidence interval (CI), 0.45–0.75], heart failure-related hospitalization (HR 0.59; 95% CI, 0.45–0.77), all-cause mortality (HR 0.51; 95% CI, 0.36–0.74) and borderline non-significant reductions in all-cause hospitalization (HR 0.85; 95% CI, 0.70–1.04) and cardiovascular mortality (HR 0.63; 95% CI, 0.39–1.02). The treatment effect of sacubitril/valsartan remains unaltered in the patient subgroup age ≥ 65 years (73%).Conclusions: In real-world settings, sacubitril/valsartan was associated with improved survival and reduced heart failure-related hospitalization compared to enalapril in Asian patients with heart failure. The effectiveness remains consistent in the older population.
Highlights
Sacubitril/valsartan, the first-in-class angiotensin receptor neprilysin inhibitor (ARNI), was proven to be superior to angiotensin-converting enzyme inhibitor (ACEI), with significant reduction in all-cause mortality and composite outcome of heart failure hospitalization or cardiovascular mortality, in patients with heart failure with reduced ejection fraction (HFrEF) in the Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial [1]
A total of 44,503 patients received a prescription of sacubitril/valsartan or enalapril between 1 July 2016 and 31 June 2019 Figure 1
2,181 patients on enalapril and 1,056 patients on sacubitril/valsartan were included in the analysis [age, mean (± SD): 74.2 ± 14.6 years; female: 44.2%; Table 1]
Summary
Sacubitril/valsartan, the first-in-class angiotensin receptor neprilysin inhibitor (ARNI), was proven to be superior to angiotensin-converting enzyme inhibitor (ACEI), with significant reduction in all-cause mortality and composite outcome of heart failure hospitalization or cardiovascular mortality, in patients with heart failure with reduced ejection fraction (HFrEF) in the Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial [1]. Based on treatment benefits observed in the pivotal trial, sacubitril/valsartan was indicated for patients with symptomatic HFrEF [3, 4]. Despite compelling evidence on the reduction of mortality and heart failure hospitalization observed in ARNI group in the pivotal trial, the generalisability of findings in clinical practice is uncertain due to the stringent trial criteria in patient recruitment. The effect of sacubitril/valsartan on survival and hospitalization risk in older patients with heart failure has not been explored. We aimed to investigate the risk of hospitalization and mortality with the use of sacubitril/valsartan vs enalapril in patients with heart failure
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