Do Entresto (sacubitril/valsartan) and Torsemide need to be discontinued before a procedure with contrast media?

From the Guidelines

Entresto (sacubitril/valsartan) and torsemide should be temporarily discontinued before procedures involving contrast media to minimize the risk of acute kidney injury and contrast-induced nephropathy. The decision to discontinue these medications is based on the potential risks associated with their use in combination with contrast agents.

• Entresto, with its angiotensin receptor blocking properties, may increase the risk of acute kidney injury when combined with contrast agents, as suggested by general principles of nephrology and cardiovascular medicine 1.
• Torsemide, a loop diuretic, should be held to prevent dehydration and reduce the risk of contrast-induced nephropathy, aligning with recommendations for minimizing contrast-induced AKI risk 1. Key considerations for the management of patients undergoing procedures with contrast media include:
• Adequate hydration to prevent contrast-induced nephropathy, as emphasized in guidelines for coronary artery revascularization and percutaneous coronary intervention 1.
• Minimizing the volume of contrast media used, particularly in patients with chronic kidney disease, to reduce the risk of contrast-induced AKI 1.
• Assessing patients for risk of contrast-induced acute kidney injury before procedures, as recommended in guidelines for percutaneous coronary intervention 1. After the procedure, Entresto and torsemide can typically be resumed 48-72 hours later, once kidney function has been assessed and confirmed to be stable, similar to the approach recommended for metformin in the context of angiography and/or angioplasty 1. The specific timing for discontinuation and resumption of these medications should be individualized based on the patient's cardiac status, kidney function, and the type of procedure being performed, with patients following their healthcare provider's specific instructions.

From the Research

Discontinuation of Entresto and Torsemide before a Procedure with Contrast Media

• There is no direct evidence in the provided studies to suggest that Entresto (sacubitril/valsartan) and Torsemide need to be discontinued before a procedure with contrast media 2, 3, 4, 5, 6.
• The studies primarily focus on the efficacy and safety of sacubitril/valsartan in patients with heart failure, its effects on renal function, and its comparison with other medications such as enalapril 2, 4, 5.
• One study mentions the reduction in loop diuretic use, including torsemide, in patients taking sacubitril/valsartan compared to enalapril, but it does not discuss the discontinuation of these medications before procedures with contrast media 4.
• Another study reviews the benefits and mechanisms of action of sacubitril/valsartan in heart failure with reduced ejection fraction, but it does not address the issue of discontinuation before procedures with contrast media 3.

Renal Function and Contrast Media

• The studies suggest that sacubitril/valsartan may have effects on renal function, including changes in estimated glomerular filtration rate (eGFR) 2.
• However, the relationship between these effects and the use of contrast media is not explicitly discussed in the provided studies 2, 3, 4, 5, 6.

Clinical Implications

• The lack of direct evidence on the discontinuation of Entresto and Torsemide before procedures with contrast media suggests that clinical decisions should be based on individual patient factors and current clinical guidelines 2, 3, 4, 5, 6.
• Further research may be necessary to fully understand the implications of using sacubitril/valsartan and torsemide in patients undergoing procedures with contrast media 2, 3, 4, 5, 6.