Angiotensin-neprilysin inhibition further reverses cardiac remodeling as compared to angiotensin inhibition in reduced heart failure patients

Background: Reduced ejection fraction heart failure patients (rEFHF) benefited from optimal medical therapy (OMT) including ACEI or ARBs, BBK and MRA. The PARADIGM-HF study showed that angiotensin receptor and neprilysin inhibition (ARNI) as compared to ACEI reduced sudden cardiac death in rEFHF. The effect of ARNI in left ventricular ejection fraction (LVEF) was not described. Purpose: To evaluate the impact of ARNI as compared to angiotensin inhibition in LVEF and left ventricular diastolic size (LVDD). Methods: We prospectively analyzed consecutive rEFHF patients (n=250) with following inclusion criteria: 1) LVEF, ≤ 40%, 2) NYHA functional class ≥ II 3) 9 months of OMT with angiotensin inhibition (ACEI/ARB), BBK and MRA. 4) Then, ACEI or ARB was changed to ARNI, which was tolerated for 9 additional months. The following parameters were collected by biplane 2D or automatic 3D echocardiogram: LVEF and LVDD. Results: After 9 months with ACEI, patients averaged an age of 69 ± 8 (76% male) and had an averaged LVDD of 62 ± 6 mm and LVEF of 31 ± 6% (80% ischemic) with NYHA of 2.4 ± -0.4. The use of BBK (93%) and MRA (83% vs.81%) was similar before and after ARNI. After 9 months with ARNI, NYHA improved to 1.5 ± 0.7 (p<0.0002), LVDD decreased (60 ± 6 mm, p<0.02) and LVEF increased (36.5 ± 8%, p<0.002). Conclusion: In a mainly ischemic rEFHF population, angiotensinneprilysin inhibition as compared to angiotensin inhibition further reversed cardiac remodeling leading an increase of LVEF, a predictor of sudden cardiac death.