In-Hospital Initiation of Angiotensin Receptor-Neprilysin Inhibitors—The Time Is Now

Heart failure (HF) is common and costly, and it results in considerable morbidity and mortality. In the Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor (ARNI) With Angiotensin-Converting Enzyme Inhibitor (ACEI) to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, patients with heart failure with reduced ejection fraction (HFrEF) who were randomized to receive sacubitril-valsartan experienced a 20% relative risk reduction in cardiovascular death or hospitalization for HF and a 16% relative risk reduction in all-cause mortality compared with those randomized to receive enalapril.¹ Despite these considerable benefits and a class I guideline recommendation, adoption of sacubitril-valsartan in clinical practice has been slow. Outpatient data from the Change the Management of Patients With Heart Failure (CHAMP-HF) registry demonstrate that only 13.9% of currently eligible outpatients with HFrEF are prescribed an ARNI, and of those treated, only 14% receive target doses.² Part of the slow uptake may be explained by low rates of ARNI initiation among those hospitalized for HF. An analysis of the Get With The Guidelines–Heart Failure registry found that only 2.3% of eligible hospitalized patients were discharged with an ARNI prescription.³ This low rate represents an important lost opportunity for ARNI introduction and may in part reflect the lack of data and comfort surrounding the use of sacubitril-valsartan in the inpatient setting.