From the Guidelines
I strongly advise against stopping Entresto (sacubitril/valsartan) even if your ejection fraction (EF) returns to normal, as this medication is crucial for maintaining improved heart function and reducing the risk of heart failure hospitalization and death. Entresto is typically prescribed for heart failure with reduced ejection fraction, and its continuation is essential for patients who remain symptomatic despite optimal treatment with an ACE-I, a beta-blocker, and an MRA, as recommended by the 2016 ESC guidelines 1.
The 2022 AHA/ACC/HFSA guideline for the management of heart failure also emphasizes the importance of continuing guideline-directed medical therapy (GDMT), including sacubitril/valsartan, in patients with heart failure with reduced ejection fraction (HFrEF), unless there are contraindications or intolerable side effects 1. Stopping Entresto could lead to worsening heart function and a return of heart failure symptoms. Any changes to your heart failure medications should only be made under the direct supervision of your cardiologist.
Key points to consider:
- Entresto works by enhancing beneficial neurohormonal pathways while blocking harmful ones, which helps reduce strain on your heart and improves its function over time.
- Even with a normal EF, these mechanisms continue to provide protection for your heart.
- Discontinuation of GDMT, including sacubitril/valsartan, has been associated with a higher risk of mortality and rehospitalization in patients with HFrEF, as shown in the OPTIMIZE-HF and GWTG-HF studies 1.
- If you're concerned about continuing Entresto, discuss this with your doctor, who can evaluate your specific situation and determine if any medication adjustments are appropriate based on your overall heart health and other medical conditions.
From the Research
Stopping Entresto When EF is Normal
- The decision to stop Entresto (sacubitril/valsartan) when the ejection fraction (EF) is normal is complex and should be based on individual patient characteristics and clinical guidelines 2, 3.
- Studies have shown that sacubitril/valsartan can be beneficial for patients with heart failure with reduced ejection fraction (HFrEF), even when the EF is not severely impaired 2.
- However, the treatment effect of sacubitril/valsartan may be modified by the EF, with greater benefits observed in patients with lower EF 2.
- In patients with advanced chronic kidney disease or hypotension, the use of sacubitril/valsartan may need to be carefully considered, as the benefits and risks may vary 3.
- The American College of Cardiology/American Heart Association guidelines recommend continuing guideline-directed medical therapy, including sacubitril/valsartan, in patients with HFrEF, even if the EF improves 4, 5.
Clinical Considerations
- Patients with HFrEF who experience a recent worsening heart failure event are at higher risk of death and hospitalization, and may require more intensive treatment, including sacubitril/valsartan 6.
- The presence of comorbidities, such as chronic kidney disease, and socioeconomic barriers, may impact the management of HFrEF and the use of sacubitril/valsartan 5, 3.
- Dose escalation of sacubitril/valsartan may be associated with better outcomes in patients with HFrEF, but should be done cautiously and under close monitoring 3.
Treatment Decisions
- The decision to stop or continue sacubitril/valsartan in patients with HFrEF should be individualized and based on a comprehensive assessment of the patient's clinical status, including EF, symptoms, and comorbidities 4, 2, 3.
- Patients with HFrEF should be closely monitored for changes in their clinical status, and adjustments to their treatment regimen, including sacubitril/valsartan, should be made as needed to optimize outcomes 5, 6.