Tolerability, Safety, and Hemodynamics of Sacubitril-Valsartan in Acutely Decompensated Heart Failure Patients with Cardiogenic Shock

Introduction A recent randomized clinical study 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. Transitioning patients in cardiogenic shock managed with pulmonary artery catheters directly from intravenous vasoactive (i.e. vasodilators or inotropes) drugs to S/V represents a potentially novel use for ARNIs. The tolerability and hemodynamic characteristics of S/V in patients with cardiogenic shock has not been previously established. Methods A single-center, retrospective analysis of all patients with heart failure and a reduced ejection fraction (HFrEF) (EF Results Twenty-two patients in the CICUs with HFrEF were started on S/V. The baseline characteristics, pertinent lab values, and hemodynamic profile (CI, SVR), are presented (Image 1). Ninety-five percent (n=21) of patients were on either of sodium nitroprusside, milrinone, dobutamine, or a combination these agents, at the time of initiation. Seventy-seven percent (n=17/22) patients were discharged on S/V with improved hemodynamics (Image 1,2). Hypotension was the most common reason for discontinuation (n=4) however one patient had both acute kidney injury and hypotension (n=1); no patients had hyperkalemia or death (n=0) (Image 2). Two of five intolerant patients were initiated on moderate (49-51) dose S/V. Conclusions The novel use S/V as oral vasodilator therapy in patients with cardiogenic shock shows favorable hemodynamic impact and tolerability. Long term tolerability and outcomes are required.