Should Entresto (sacubitril/valsartan) be continued or discontinued in the preoperative period for patients with heart failure with reduced ejection fraction?

Management of Entresto (Sacubitril/Valsartan) in the Preoperative Period

For patients with heart failure with reduced ejection fraction (HFrEF), it is reasonable to continue Entresto (sacubitril/valsartan) in the perioperative period, unless contraindicated, to reduce the risk of worsening heart failure. 1

Rationale for Continuing Entresto Preoperatively

• The 2024 AHA/ACC perioperative cardiovascular management guidelines specifically recommend that in patients with compensated heart failure undergoing noncardiac surgery, it is reasonable to continue guideline-directed medical therapy (GDMT) in the perioperative period (Class 2a, Level of Evidence C-LD) 1
• Entresto (sacubitril/valsartan) is considered part of GDMT for HFrEF and falls under this recommendation
• Discontinuation of sacubitril/valsartan has been associated with:
  • Deterioration of left ventricular ejection fraction
  • Worsening of functional class
  • These negative outcomes occur despite patients being switched to conventional therapy with ACEIs or ARBs 2

Perioperative Management Algorithm

1. Preoperative Assessment:

   • Evaluate current heart failure status
   • Assess for signs of decompensation (increased dyspnea, edema, weight gain)
   • Check renal function and electrolytes
   • Review blood pressure readings (avoid continuing if systolic BP <100 mmHg)

2. Day of Surgery:

   • If patient is hemodynamically stable with compensated heart failure:
     • Continue Entresto at usual dose
   • If patient shows signs of hemodynamic instability or hypotension:
     • Hold morning dose and reassess postoperatively

3. Intraoperative Considerations:

   • Monitor blood pressure closely
   • Be prepared for potential hypotension, especially during anesthesia induction
   • Have vasopressors available if needed

4. Postoperative Management:

   • Resume Entresto as soon as patient is hemodynamically stable
   • Monitor renal function and electrolytes
   • Assess volume status carefully

Special Considerations

• Hypotension Risk: Entresto may cause hypotension, especially in combination with anesthetics. If significant hypotension is anticipated or occurs, temporary dose reduction may be necessary
• Renal Function: Monitor closely, especially in patients with pre-existing renal impairment
• Electrolytes: Watch for hyponatremia, which has been reported with Entresto 3

Exceptions to Continuing Entresto

Hold or discontinue Entresto preoperatively if:

• Severe hypotension (systolic BP <90 mmHg)
• Acute kidney injury or significant worsening of renal function
• Hyperkalemia (K+ >5.4 mEq/L)
• Angioedema history with ACEIs/ARBs
• Major surgery with anticipated significant blood loss or hemodynamic instability

Benefits of Continuing Entresto

• Maintains heart failure control and hemodynamic stability
• Prevents deterioration in cardiac function that can occur with discontinuation 2
• Provides ongoing benefits regardless of heart failure duration 4
• Reduces biomarkers associated with heart failure progression 4

Pitfalls to Avoid

• Abrupt discontinuation without substitution of alternative RAAS inhibitor
• Failure to monitor blood pressure, especially during anesthesia induction
• Inadequate volume status assessment in the perioperative period
• Restarting at full dose in hemodynamically unstable patients

By following these recommendations and maintaining Entresto therapy when appropriate in the perioperative period, clinicians can help optimize outcomes for patients with HFrEF undergoing surgery while minimizing the risk of heart failure decompensation.