Initiation, Treatment Response Evaluation, and Safety Monitoring of Angiotensin Receptor/Neprilysin Inhibitors (Sacubitril/Valsartan) in the Management of Heart Failure in India: An Expert Group Recommendations

Abstract

Angiotensin receptor/neprilysin inhibitors (ARNI) have become a pillar of heart failure (HF) management. Clinicians gain practical insight into the use of sacubitril/valsartan in patients with HF with reduced ejection fraction (EF) from a comprehensive overview based on clinical experience with ARNI therapy. The objective was to develop a consensus document addressing common concerns regarding the use of ARNI in patients with HF in clinical settings in India. Subject matter experts (SMEs) from India with decision-making expertise in the management of HF were identified to address experiences of ARNI use in Indian patients, its function in reversing myocardial remodeling, improvement in health status, and its safety. In regional meetings, five SMEs from India who consented to participate discussed data from practical experiences and current evidence. ARNI has been shown to substantially enhance EF 5%–10% in a majority of HF patients, although the range of improvement could vary widely in a few patients. Angiotensin-converting enzyme inhibitors and angiotensin II receptor blocker antagonists have been eclipsed by ARNI. Patients who have diminished or declining estimated glomerular filtration rates are more likely than those with normal renal function to experience hyperkalemia. It is prudent to consistently monitor potassium levels in patients with borderline chronic kidney disease. In India, potassium binders may be used to temporarily control hyperkalemia caused by ARNI. Patients with a systolic blood pressure of <100 mmHg may initiate taking ARNI while being tracked for clinical symptoms. In clinical practice, symptomatic improvement with ARNI is observed soon after initiating, even before alterations noted in echocardiography.