Introduction Sacubitril inhibits neprilysin in the kidneys, preventing degradation of natriuretic peptides, thus augmenting natriuresis and vasodilation. However, neprilysin is also expressed in the central nervous system and is involved in the degradation of beta amyloid, which has been associated with Alzheimer's disease (AD) and other cognitive defects. Experimental studies with sacubitril/valsartan (S/V) have fueled theoretical concerns about neurocognitive side effects, but clinical data are scarce. Hypothesis We hypothesized that 5-year incidence of new neurocognitive diagnoses (AD, dementia, and cognitive decline) among patients with HF who have switched to S/V does not differ from that of patients with HF receiving an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) alone. Methods Using data from the TriNetX electronic health records network, we examined relevant neurological outcomes in (1) an S/V cohort, comprising of adults (age ≥18) with systolic HF (ICD-10 I50.2) who were switched from ACEi or ARB to S/V between 2015 and 2019 (to allow for ≥1 year of followup) and (2) a propensity-matched (for over 100 clinical characteristics) cohort of adults with systolic HF who were receiving exclusively ACEI or ARB during the same period (to eliminate temporal bias). We evaluated for new: (1) AD (ICD-10: G30); (2) dementia (ICD-10: F01-F03); and (3) any cognitive decline (ICD-10: R41.8). We used Cox proportional hazards models to compare incidence between matched cohorts. Results The baseline characteristics of the matched cohorts (N=19,553 for each cohort) were well balanced (Table 1); all standardized mean differences were <0.1, indicating adequate matching. Kaplan-Meier mortality at 5 years was 25.8% in S/V vs. 31.2% in ACEi/ARB (log-rank P<0.001). After excluding patients with prevalent diagnoses of interest at baseline, the incidences of AD, dementia, and cognitive decline were all lower in the S/V group (Table 2). Conclusions Despite theoretical concerns, the incidence of neurocognitive diagnoses was lower among S/V recipients in this large-cohort, propensity-matched analysis of systolic HF patients. Whether S/V is beneficial in this aspect needs prospective evaluation. Sacubitril inhibits neprilysin in the kidneys, preventing degradation of natriuretic peptides, thus augmenting natriuresis and vasodilation. However, neprilysin is also expressed in the central nervous system and is involved in the degradation of beta amyloid, which has been associated with Alzheimer's disease (AD) and other cognitive defects. Experimental studies with sacubitril/valsartan (S/V) have fueled theoretical concerns about neurocognitive side effects, but clinical data are scarce. We hypothesized that 5-year incidence of new neurocognitive diagnoses (AD, dementia, and cognitive decline) among patients with HF who have switched to S/V does not differ from that of patients with HF receiving an angiotensin-converting enzyme inhibitor (ACEi) or an angiotensin receptor blocker (ARB) alone. Using data from the TriNetX electronic health records network, we examined relevant neurological outcomes in (1) an S/V cohort, comprising of adults (age ≥18) with systolic HF (ICD-10 I50.2) who were switched from ACEi or ARB to S/V between 2015 and 2019 (to allow for ≥1 year of followup) and (2) a propensity-matched (for over 100 clinical characteristics) cohort of adults with systolic HF who were receiving exclusively ACEI or ARB during the same period (to eliminate temporal bias). We evaluated for new: (1) AD (ICD-10: G30); (2) dementia (ICD-10: F01-F03); and (3) any cognitive decline (ICD-10: R41.8). We used Cox proportional hazards models to compare incidence between matched cohorts. The baseline characteristics of the matched cohorts (N=19,553 for each cohort) were well balanced (Table 1); all standardized mean differences were <0.1, indicating adequate matching. Kaplan-Meier mortality at 5 years was 25.8% in S/V vs. 31.2% in ACEi/ARB (log-rank P<0.001). After excluding patients with prevalent diagnoses of interest at baseline, the incidences of AD, dementia, and cognitive decline were all lower in the S/V group (Table 2). Despite theoretical concerns, the incidence of neurocognitive diagnoses was lower among S/V recipients in this large-cohort, propensity-matched analysis of systolic HF patients. Whether S/V is beneficial in this aspect needs prospective evaluation.