ARNI Initiation in Acute Heart Failure
Evidence for ARNI Initiation
- The American College of Cardiology recommends ARNI as de novo treatment in hospitalized patients with acute HF before discharge, based on improvements in health status, reduction in NT-proBNP, and improved left ventricular remodeling parameters compared to ACEi/ARB (Class I recommendation) 1
- The PIONEER-HF trial demonstrated that ARNI initiated after hemodynamic stabilization in acute decompensated HF reduced NT-proBNP levels without increased rates of adverse events when compared with enalapril 1, 2
- The TRANSITION trial showed that early initiation of ARNI either before or after discharge had similar safety outcomes, suggesting that early initiation simplifies management rather than requiring initial ACEi uptitration followed by switching 1, 2
Patient Eligibility and Initiation
- The American Heart Association and American College of Cardiology recommend initiating ARNI in patients with HFrEF and LVEF ≤40% 1
- Patients should have NYHA class II-III symptoms (or acute decompensation) and be hemodynamically stable (systolic BP >100 mmHg, no vasopressor requirement) 1
- A history of angioedema is a contraindication for ARNI use (Class 3: Harm) 1, 2
Dosing Strategy
- The target dose of ARNI is 97/103 mg twice daily, which should be titrated every 2-4 weeks as tolerated 1
- The initial dose of ARNI can be 24/26 mg twice daily if the patient is previously on low-dose ACEi/ARB, or 49/51 mg twice daily if the patient is previously on valsartan ≥160 mg daily equivalent 3
Critical Safety Considerations
- Concomitant ACEi use or <36 hours since last ACEi dose is a contraindication for ARNI use (Class 3: Harm) 1, 2
- Serum potassium >5.0 mEq/L requires close monitoring 4, 5
- Significant renal impairment (eGFR <30 mL/min) requires dose adjustment 6, 7