Restarting Sacubitril/Valsartan After NSTEMI/CHF Hospitalization

Introduction to Restarting Sacubitril/Valsartan

The American College of Cardiology recommends restarting sacubitril/valsartan in hemodynamically stable patients after NSTEMI or acute decompensated heart failure, ideally before hospital discharge, with demonstrated safety and superior outcomes compared to delaying therapy 1, 2, 3

Restart sacubitril/valsartan once the patient is hemodynamically stable, which means resolution of acute heart failure symptoms and systolic blood pressure stable, according to the American College of Cardiology 1, 3
The American College of Cardiology states that systolic blood pressure should be stable, ideally >100 mmHg, though lower pressures may be acceptable if asymptomatic 1, 4
No ongoing signs of cardiogenic shock or hypoperfusion are required for restart, as per the American College of Cardiology 5

The PARADISE-MI trial showed sacubitril/valsartan did not significantly reduce the primary outcome when started within 7 days of MI in patients with newly depressed EF <40% or signs of heart failure, according to the American College of Cardiology 5, 2, 3
Despite this uncertainty, if the patient has established HFrEF, sacubitril/valsartan remains indicated and should be restarted based on their chronic heart failure diagnosis, as recommended by the American College of Cardiology 2, 3

Start at the appropriate dose based on prior exposure and clinical factors, such as 49/51 mg twice daily if previously on high-dose ACE inhibitor or ARB, or 24/26 mg twice daily for low/medium-dose prior ACE inhibitor or ARB exposure, according to the American College of Cardiology 4
Titrate to target dose of 97/103 mg twice daily every 2-4 weeks as tolerated, as recommended by the American College of Cardiology 4

Mandatory 36-hour washout if switching from an ACE inhibitor to avoid angioedema risk, as required by the FDA and recommended by the American College of Cardiology 3, 4
Monitor for hypotension, which occurred in up to 25% of PIONEER-HF patients, and ensure patient is not volume-depleted before initiation, according to the American College of Cardiology 1

Do not permanently discontinue or reduce dose for asymptomatic hypotension, mild, transient creatinine elevations, or mild hyperkalemia, as recommended by the American College of Cardiology 4
Do not delay initiation until after discharge, as the TRANSITION trial showed similar safety whether started before or after discharge, according to the American College of Cardiology 1, 2, 3
Do not fail to uptitrate to target dose, as approximately 50% of patients can achieve target dose within 10 weeks, and higher doses provide greater mortality benefit, as recommended by the American College of Cardiology 1, 4