Sacubitril/Valsartan (Elderly HFrEF)

How it works

Sacubitril inhibits neprilysin to raise beneficial natriuretic peptides, while valsartan blocks the angiotensin II receptor, together promoting vasodilatation, natriuresis and reduced cardiac strain.

Prescribing in practice

• It must never be combined with, or started within the washout period of, an ACE inhibitor because of serious angioedema risk, and is contraindicated with aliskiren in diabetes and in a history of ACE-inhibitor angioedema.
• In older people watch closely for symptomatic hypotension, hyperkalaemia and renal impairment, and titrate gradually from a lower starting dose.
• It can raise potassium, especially alongside potassium-sparing diuretics or supplements; review concurrent therapy.

Monitoring

Monitor blood pressure, renal function and potassium before and during titration, with particular vigilance in frail older patients.

Counselling the patient

• An ACE inhibitor must be stopped for the recommended gap before starting this medicine.
• Report dizziness or any swelling of the face, lips or tongue immediately.
• Rise slowly from sitting or lying to reduce light-headedness.

Evidence & guidelines

The PARADIGM-HF trial showed sacubitril/valsartan reduced cardiovascular death and heart-failure hospitalisation versus enalapril in HFrEF, and NICE recommends it for eligible patients.