From the Research
Entresto (sacubitril/valsartan) can be used in patients with systolic heart failure even with relatively low blood pressure, but caution is needed, and a systolic blood pressure of at least 100 mmHg is recommended before starting Entresto, though some clinicians may initiate therapy at systolic pressures as low as 90-95 mmHg in carefully selected patients, as supported by the most recent study 1. When considering the use of Entresto in patients with heart failure, it is crucial to weigh the benefits of the medication against the potential risks, particularly hypotension. The medication's ability to improve heart function by combining an angiotensin receptor blocker (valsartan) with a neprilysin inhibitor (sacubitril) must be balanced against its potential to cause hypotension as a side effect.
Key Considerations for Entresto Use
- Starting Blood Pressure: A systolic blood pressure of at least 100 mmHg is generally recommended before initiating Entresto therapy, although initiation at lower pressures (90-95 mmHg) may be considered in selected patients, as noted in studies such as 2 and 3.
- Monitoring and Dose Adjustment: Regular blood pressure monitoring is essential, especially during dose adjustments, to mitigate the risk of hypotension. If blood pressure drops below 90 mmHg or if the patient experiences symptoms of hypotension, dose reduction or temporary discontinuation may be necessary, as suggested by 1.
- Asymptomatic Hypotension: The management of asymptomatic hypotension in patients on Entresto is an area of interest, with recent studies like 1 indicating that continuation of therapy may be beneficial even after the occurrence of asymptomatic hypotension, highlighting the need for careful patient monitoring and management.
Clinical Decision Making
In clinical practice, the decision to initiate or continue Entresto therapy in patients with heart failure must consider the individual patient's risk profile, including their blood pressure, symptoms, and overall clinical status. The most recent and highest quality evidence, such as the study published in 2025 1, should guide these decisions to ensure the best possible outcomes in terms of morbidity, mortality, and quality of life.
Evidence Summary
The evidence from studies 4, 5, 2, 1, and 3 supports the use of Entresto in heart failure patients, with careful consideration of blood pressure and potential hypotension. The most recent study 1 provides valuable insights into the management of asymptomatic hypotension, emphasizing the importance of continued therapy when possible. By prioritizing the most recent and highest quality evidence, clinicians can make informed decisions that balance the benefits and risks of Entresto therapy.