What is the role of Valsartan (Angiotensin II receptor antagonist) in the treatment of ischemic dilated cardiomyopathy (DCM)?

Valsartan in Ischemic Dilated Cardiomyopathy

Valsartan is strongly recommended as the preferred angiotensin receptor blocker (ARB) for patients with ischemic dilated cardiomyopathy (DCM), particularly when ACE inhibitors are not tolerated. 1, 2

Role of Valsartan in Ischemic DCM

• Valsartan is specifically indicated in clinically stable patients with left ventricular failure or left ventricular dysfunction following myocardial infarction to reduce the risk of cardiovascular mortality 3
• Valsartan blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor, which helps improve cardiac function in ischemic DCM 3
• In the VALIANT trial, valsartan was shown to be as effective as captopril in patients at high risk for cardiovascular events after myocardial infarction, establishing its efficacy specifically for post-MI left ventricular dysfunction 2
• ARBs like valsartan are particularly beneficial for patients who cannot tolerate ACE inhibitors due to side effects such as cough 4

Guideline Recommendations

• The American College of Cardiology/American Heart Association guidelines specifically recommend valsartan and candesartan as the ARBs with established efficacy for heart failure after myocardial infarction 2
• ARBs should be prescribed at discharge for STEMI patients who are intolerant of ACE inhibitors and have either clinical or radiological signs of heart failure and LVEF <0.40 (Class I recommendation, Level of Evidence B) 2
• In patients who tolerate ACE inhibitors, valsartan can be used as an alternative in the long-term management of STEMI patients with heart failure or LVEF <0.40 (Class IIa recommendation) 2
• For patients with ischemic DCM and preserved EF, the usefulness of ARBs like valsartan in treating symptoms (angina and dyspnea) is not well established (Class 2b recommendation) 2

Comparative Efficacy with Other Treatments

• ACE inhibitors remain the first-line therapy for inhibition of the renin-angiotensin-aldosterone system in patients with ischemic DCM, with ARBs (specifically valsartan) recommended when patients are intolerant to ACE inhibitors 2, 1
• Recent evidence suggests that ARBs may be associated with greater recovery of cardiac function than ACE inhibitors in patients with DCM and reduced LVEF 5
• In the VALUE trial, valsartan-based therapy was comparable to amlodipine-based therapy in terms of cardiac mortality and morbidity in patients with hypertension and high risk of cardiovascular events 2
• Sacubitril/valsartan has shown superior outcomes compared to ACE inhibitors alone in patients with LVEF ≤35% (of which 60% had ischemic etiology), reducing heart failure hospitalization and cardiovascular death 2

Special Considerations

• Valsartan has been shown to suppress myocardial hypertrophy and fibrosis, and improve hemodynamics in animal models of post-myocarditis dilated cardiomyopathy 6
• Sacubitril/valsartan may decrease myocardial ischemia through its effect in reducing LV wall stress and improving coronary circulation, with post-hoc analyses showing reduced risk of coronary events compared to ACE inhibitors 2
• Sacubitril/valsartan therapy has been associated with reduction in both atrial and ventricular arrhythmias in DCM patients with reduced ejection fraction 7
• The prognosis of patients with DCM has significantly improved over the past decades, partly due to the increased use of ACEI/ARB and beta blockers 8

Practical Implementation

• Monitor renal function and potassium levels when initiating valsartan, particularly in patients with pre-existing renal impairment 4
• The combination of an ACE inhibitor and valsartan is not generally recommended as it increases adverse effects without providing additional benefits 2, 4
• For younger patients (≤45 years) with nonobstructive HCM due to a pathogenic cardiac sarcomere genetic variant and mild phenotype, valsartan may be beneficial to slow adverse cardiac remodeling 2
• Valsartan should be part of a comprehensive treatment approach for ischemic DCM that includes beta-blockers, aldosterone antagonists, and in appropriate patients, SGLT2 inhibitors 1, 2