Safety of Initiation of Sacubitril/Valsartan in ICU Patients with Advanced Decompensated Heart Failure

Introduction Sacubitril/valsartan (S/V) is superior to enalapril in reducing mortality and morbidity in patients with chronic stable heart failure with reduced ejection fraction (HFrEF). The goal of this investigation was to determine if S/V could be used safely as an oral vasodilator when weaning intravenous vasoactive therapies. Methods Invasive hemodynamic data was prospectively collected from ten consecutive patients with Stage D HFrEF admitted to the heart failure intensive care unit (HF-ICU) for treatment of acute decompensated heart failure. All patients were admitted for pulmonary artery catheter hemodynamic guided therapy and were initiated on S/V. Results Ten patients were included in the cohort and were on either intravenous inotropes n=3 or sodium nitroprusside (SNP) n=7. Mean dose of SNP was 151 mcg/min, mean dose for dobutamine was 5 mcg/kg/min and milrinone dose was 0.5 mcg/kg/min. Mean age was 50 years old, with 4 females and 6 males. Three patients with ischemic cardiomyopathy, 7 non-ischemic cardiomyopathy. All patients were successfully weaned from inotropes or SNP and tolerated S/V initiation. Average mean arterial pressure of the cohort decreased from 88.3 to 80.6 mmHg (9% reduction), right atrial pressure decreased from 15.6 to 5 mmHg (70% reduction), mean pulmonary artery pressure decreased from 43.6 to 27.3 mmHg (37% reduction), pulmonary capillary wedge pressure decreased from 28.4 to 14.7 mmHg (48% reduction), mean cardiac index increased from 1.7 to 2.56 l/min/m2 (51% increase) and mixed venous saturation increased from 52.6 to 67.2% (22% increase). The detailed hemodynamic results for each patient are summarized in Table 1. S/V was well tolerated and hemodynamics were stable after weaning IV therapy. Conclusion Patients with cardiogenic shock tolerated initiation of S/V and subsequent successful weaning of intravenous vasodilator or inotropic therapy. These preliminary novel hemodynamic observations suggest S/V may be initiated safely in ICU patients and facilitate weaning from intravenous therapies.