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Editor's Note
July 10, 2019

Impediments to Implementing Guideline-Directed Medical Therapies

Author Affiliations
  • 1Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles
  • 2Associate Editor, JAMA Cardiology
  • 3Duke Clinical Research Institute, Duke University, Durham, North Carolina
  • 4Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 5Deputy Editor, JAMA Cardiology
JAMA Cardiol. 2019;4(8):830-831. doi:10.1001/jamacardio.2019.2276

Despite clinical trial evidence demonstrating improvements in clinical outcomes with new therapies in patients with cardiovascular disease, uptake of these therapies has been stubbornly slow, variable, and incomplete. The angiotensin receptor–neprilysin inhibitor (ARNI) sacubitril/valsartan has been shown to improve health status, decrease hospitalizations, and reduce mortality in patients with heart failure with reduced ejection fraction (HFrEF) beyond the levels that can be achieved with angiotensin-converting enzyme inhibitor therapy. Despite these considerable benefits and a class I guideline recommendation to replace angiotensin-converting enzyme inhibitor or angiotensin receptor antagonist therapy with ARNI therapy in patients who remain symptomatic, adoption of ARNI therapy in clinical practice has been sluggish.1 Nonuniform inclusion on formularies, prior authorization requirements, and out-of-pocket costs borne by patients have been reported to be important barriers to greater use of novel cardiovascular therapies, including ARNI therapy.