Angiotensin Neprilysin Inhibitors Could Benefit Patients with HFrEF

Patients who have heart failure with a reduced ejection fraction (HFrEF) could benefit from angiotensin neprilysin inhibitors (ARNI), according to new research presented at the Heart Failure Society of America 2024 Annual Meeting.¹ The authors of the study said strategies are currently being implemented to increase ARNI prescription rates.

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The phase 3 PARADIGM-HF (NCT01035255) study, which evaluated the efficacy and safety of the ARNI sacubitril/valsartan in patients with HFrEF, showed that the drug was superior to the angiotensin-converting enzyme (ACE) inhibitor enalapril in reducing the risk of death and hospitalization for heart failure. However, high prescription costs are a current barrier to prescribing ARNI over ACE inhibitors or angiotensin receptor blockers (ARB).

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Investigators from the Emory University School of Medicine conducted a study to compare patients on ACE inhibitors or ARBs with patients not taking any renin-angiotensin system inhibitors (RASi). Data was collected from the Atlanta Veterans Administration (VA) heart failure dashboard, which tracks heart failure metrics and goal-directed medical therapy (GDMT) prescription rates. The study also included a survey of 59 providers regarding their knowledge and perception of ACE, ARB and ARNI prescriptions.

Patients were excluded from the study if they had a glomerular filtration rate (GFR) of less than 30 milliliters per minute or a documented allergy to any of the medications. The study cohort included 510 patients living with HFrEF, of which 324 were taking an ACE or ARB and 186 who were not currently taking any medications. The average age of patients taking an ACE or ARB was 69, compared to 70 for patients not taking any medication.

The study found that there was no statistical difference between systolic blood pressure, ejection fraction and GFR between the 2 groups. Both of the groups had a systolic blood pressure above 120, which suggest that most patients could benefit from taking ARNIs. The study also found the prescription rate of ARNIs at the Atlanta VA was 38.8%, compared to 42.3% at other VA hospitals. However, the VA prescription rate is higher than the 6% to 22% at non-VA hospitals.

Of the providers who responded to the survey, 64% believed the ARNI prescription rate at the Atlanta VA was below the VA national average and 66% believed it was below the national average. The 3 most common limitations to prescribing ARNI included cost or prior authorization, side effects and patients already on an ACE or ARB.

“The VA population is a key population to evaluate ARNI prescription rates as the highest barrier, cost, is minimized as drugs are heavily subsidized through the VA pharmacy,” the authors concluded. “This study suggests that most patients with HFrEF not on ARNI could benefit from ARNI. Quality improvement initiatives are needed to understand RASi prescription patterns and to increase the rate of Sacubitril/valsartan prescriptions at the Atlanta Veterans Affairs Hospital.”

Click here for more coverage of the Heart Failure Society of America 2024 Annual Meeting.

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Reference

1. Gillet AS, Kohli P. Characteristics Of Patients Eligible For Sacubitril Valsartan Optimization and Provider’s Attitudes Towards Renin-Angiotensin System Inhibitors. Presented at: Heart Failure Society of America 2024 Annual Meeting; September 27-30, 2024; Atlanta, GA. Poster 386.