Sacubitril-Valsartan versus Standard Anti-Hypertensives in Left Ventricular Assist Device Patients

Introduction Hypertension is a common comorbidity affecting patients with left ventricular assist devices (LVAD). Left uncontrolled, it may lead to a decrease in LVAD support and increase the risk for stroke. The ISHLT defines hypertension in LVAD patients as a mean arterial pressure (MAP) of > 90 mmHg and recommends aggressive management utilizing standard heart failure medications. Sacubitril-valsartan (Entresto®) is an angiotension II blocker-neprilysin inhibitor with potent anti-hypertensive effects approved for the treatment of heart failure with a reduced ejection fraction. Our aim was to assess blood pressure control with sacubitril-valsartan versus standard anti-hypertensive therapy in our LVAD patients. Methods This is a single center evaluation of MAP reduction, stroke and readmission rates associated with sacubitril-valsartan versus standard anti-hypertensives in our HeartMate II (HMII) LVAD patients with a diagnosis of hypertension. Initial MAP measured by Doppler was assessed prior to initiation or intensification of therapy post LVAD implant and compared to the most recent clinic visit MAP. Patients were excluded if they did not have a recent MAP, were on intravenous inotropic therapy, were non-compliant or were implanted with an LVAD other than HMII. Results Due to exclusion criteria, only 26 patients were assessed, with 12 treated with sacubitril-valsartan. Patients treated with sacubitril-valsartan had an average MAP reduction of 20 mmHg. Those on standard anti-hypertensives had an average MAP reduction of 12 mmHg. Of the patients in the standard group, 46% had a documented stroke whereas no patients in the sacubitril-valsartan group had a stroke. Readmissions were also lower in the sacubitril-valsartan group with these patients requiring an average of three fewer hospitalizations. Adverse effects associated with sacubitril-valsartan were reported in three patients and included hypovolemia and lightheadedness leading to two discontinuations. Discussion In this single center retrospective analysis of HMII LVAD patients, sacubitril-valsartan provided a larger reduction in MAP when compared to standard anti-hypertensive therapy. Patients in the sacubitril-valsartan group were less likely to have a stroke and required fewer readmissions than those on standard therapies. Due to the non-randomized, retrospective nature of this study, confounding factors cannot be ruled out. Randomized trials are ongoing to assess the clinical benefits of its use on a larger scale.