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Editor's Note
December 2016

Angiotensin Receptor Neprilysin Inhibitor Use UrgencyFestina Lente

JAMA Cardiol. 2016;1(9):973. doi:10.1001/jamacardio.2016.3534

In this issue of JAMA Cardiology, Packer1 offers a provocative viewpoint titled “Angiotensin Neprilysin Inhibition for Patients With Heart Failure: What If Sacubitril/Valsartan Were a Treatment for Cancer?” This article challenges the absence of urgency in the treatment of patients with heart failure, noting that the malignancy of heart failure can be similar to cancer. The compelling argument for more rapid uptake is a poignant and appropriate point for discussion by the larger cardiovascular community. This is not an isolated observation, as the uptake of other evidence-based therapies for heart failure, including aldosterone antagonists, cardiac resynchronization therapy devices, implantable cardioverter defibrillators, isosorbide dinitrate/hydralazine, and even evidence-based β-blockers, was not robust. Moreover, few, if any, cardiovascular therapies are fully penetrated in at-risk patient groups.

Several themes are pertinent regardless of the intervention in question: The translation of evidence into guidelines and subsequent clinical practice remains a deliberate and methodical process. Extrapolating clinical trial results to an unselected patient population, which typically is older and harbors more comorbidities, remains an inexact science. Despite well-done randomized clinical trials, risk remains an uncertainty. Finally, review of the primary data with methodological rigor and in a way that is systematic, balanced, and transparent (eg, guideline writing committees) is necessary for an increasingly skeptical community to confirm that clinical trial results are irrefutable and merit uptake into clinical practice.

What is the value of speed? The successes we have seen in cardiovascular medicine with enhanced patient-centered quality of care and markedly improved outcomes has been driven largely by an evidence base that is robust, actionable, and resilient, allowing for the incorporation of new findings into well-developed and trustworthy guidelines. Speed alone has little virtue.

Festina lente is a classical Greek phrase that translates to “hasten slowly.” This phrase has a colorful history but may have originated on the battlefield. In contemporary use, it sets the tone for an appropriate sense of urgency that is also supported by a commitment to due diligence. The potential of valsartan/sacubitril therapy with optimal implementation is substantial,2 and its use has been endorsed by updated American College of Cardiology/American Heart Association/Heart Failure Society of America heart failure guidelines.3 But for many in the community, who appropriately pause and ponder over new interventions, perhaps the mantra remains festina lente.

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Article Information

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Fonarow has received personal fees from Amgen, ZS Pharma, Novartis, Medtronic, Janssen, and St. Jude Medical, and has received grants from the National Institutes of Health. No other disclosures were reported.

References
1.
Packer  M.  Angiotensin neprilysin inhibition for patients with heart failure: what if sacubitril/valsartan were a treatment for cancer?  [published online September 21, 2016]. JAMA Cardiol. doi:10.1001/jamacardio.2016.3053
2.
Fonarow  GC, Hernandez  AF, Solomon  SD, Yancy  CW.  Potential mortality reduction with optimal implementation of angiotensin receptor neprilysin inhibitor therapy in heart failure  [published online June 22, 2016]. JAMA Cardiol. doi:10.1001/jamacardio.2016.1724PubMed
3.
Yancy  CW, Jessup  M, Bozkurt  B,  et al.  2016 ACC/AHA/HFSA focused update on new pharmacological therapy for heart failure: an update of the 2013 ACCF/AHA guideline for the management of heart failure  [published online May 20, 2016]. Circulation. doi:10.1161/CIR.0000000000000435PubMed
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