When to Switch Patients from an ACE Inhibitor to an ARNI

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The MD Magazine Peer Exchange “Managing Heart Failure Today: Current Best Practices and New Treatment Options” features a panel of physician experts discussing key factors to consider when making treatment decisions for patients with heart failure and their own clinical experiences with recently approved medications for the treatment of heart failure.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons, and an associate director of Surgical Intensive Care at New York-Presbyterian Hospital.

The panelists are:

• Michael Felker, MD, MHS, professor of medicine and chief of the Heart Failure Section at Duke University School of Medicine, in Durham, NC
• Milton Packer, MD, Distinguished Scholar in Cardiovascular Science, Baylor Heart and Vascular Hospital, Baylor University Medical Center, in Dallas, TX
• Scott Solomon, MD, Senior Physician and director of Non-Invasive Cardiology at Brigham and Women’s Hospital, and Edward D. Frohlich Distinguished Chair and professor of medicine at Harvard Medical School, in Boston, MA
• John R. Teerlink, MD, director of Heart Failure at San Francisco Veterans Affairs Medical Center and professor of medicine at UCSF in San Francisco, CA

Milton Packer, MD: The most important thing, or way, of looking at guidelines is, again, if you use the cancer analogy and you say, “We have had 3 central drugs that have always been given together to reduce the progression of disease and prolong life.” What we have learned in the past year or 2, and what the guidelines now recommend, is that the components of those 3 therapies can now be meaningfully enhanced. And specifically, one can enhance the effect of the beta-blocker in patients who are already taking a beta-blocker by adding ivabradine if the heart rate is over 70 or 75. What we’ve also learned is that if you, instead of using an ACE (angiotensin-converting enzyme) inhibitor, [you] use sacubitril/valsartan, you double the mortality effects of the ACE inhibitor. That’s a pretty dramatic statement.

Peter Salgo, MD: Right. But syntactically, let me just improve that.

Milton Packer, MD: The benefit?

Peter Salgo, MD: The benefit. You’re not doubling your death. You’re doubling the life of the ACE inhibitor. You double the benefit.

Milton Packer, MD: The benefit, the mortality reduction.

Peter Salgo, MD: So, if I’m hearing you correctly, if you’re going to double the benefit, are you actively campaigning here? I don’t mean this in a political sense, but scientifically, for the replacement of ACE inhibitors by ARNIs (angiotensin receptor/neprilysin inhibitors)?

Milton Packer, MD: It’s not a campaign. It’s the right thing to do.

Peter Salgo, MD: Well, that’s my point. Scientifically, is it the right thing to do?

John R. Teerlink, MD: That’s what’s so great about the PARADIGM-HF study. It was designed to actually address this very question of, if you compare an ACE inhibitor directly, head-to-head, with an ARNI (sacubitril/valsartan), who wins? Eight thousand-plus patients said sacubitril/valsartan won.

Peter Salgo, MD: This sounds like such a big win.

Scott Solomon, MD: We talked before about the 20% reduction in risk. But we looked at it in a different way that might even be more meaningful to patients. We [questioned that] if you were on this drug for the rest of your life, what would it give you in terms of extended life or a lifetime free of heart failure [symptoms]? It turns out to be, for the average-aged patient that we’re treating, about 1.5 to 2 years. Now, that is, I think, much more meaningful to a patient.

Peter Salgo, MD: One-and-a-half to 2 years is big.

Scott Solomon, MD: Then 20%.

Milton Packer, MD: Suppose you had a patient with cancer and they were already getting a conventional drug, and a new drug came in that would prolong their lives 1.5to 2 years more than the drug that they were taking before. Wouldn’t you use it?

Peter Salgo, MD: Well, I would say yes. I think we’re looking at some chemotherapies that are giving people 5 months.