Angiotensin Receptor Neprilysin Inhibitors (ARNI)
Angiotensin Receptor Neprilysin Inhibitor (ARNI) combines the neprilysin inhibitor (sacubitril) with the angiotensin receptor blockade (valsartan). Sacubitril/valsartan (trade name Entresto) has been shown to be superior to the ACE inhibitor (enalapril) in reducing cardiovascular mortality and hospitalisation due to HFrEF.
Sacubitril/valsartan is recommended as a replacement for an ACE inhibitor or an ARB. Indications include:
- Symptomatic with NYHA class II-IV
- Left ventricular EF ≤ 40%
- Be on concomitant optimal standard heart failure treatment that includes maximum tolerated dose of beta blocker (unless contraindicated)
- Be stabilised on an ACE inhibitor or ARB (unless contraindicated)
- Do not co-administer with an ACEI or ARB
- Switching from an ACEI: Wait at least 36 hours after last dose of ACEI prior to commencement
- Switching from an ARB: No washout period is required and commence Sacubitril-Valsartan when next dose would have been due
- Local restrictions and healthcare system subsidies should be considered when initiating ARNI
Ivabradine may be considered for patients with HFrEF, with a recent hospital admission and who are in sinus rhythm with a heart rate >70 bpm despite receiving optimal beta-blocker therapy. Ivabradine decreases heart rate by inhibiting the sinus node.
Ivabradine reduces cardiovascular mortality and HF hospitalisations in patients with symptomatic HFrEF, who have had a recent hospital admission and who are in sinus rhythm with a heart rate >70 bpm.
Digoxin may be considered in patients with ongoing symptoms of HF despite optimised pharmacotherapy (i.e., ACE inhibitor, beta-blocker and MRA diuretic therapy) to reduce the risk of hospitalisation. Digoxin is often prescribed to control ventricular rate in patients with co-existing AF.
Hydralazine-isosorbide dinitrate combination should be considered in patients who are actually intolerant of ACE inhibitors and ARBs or for whom these agents are contraindicated.
Fish oil (n-3 polyunsaturated fatty acids)
A small beneficial effect of fish oil supplementation on cardiovascular death and hospitalisation has been demonstrated in one large randomised trial of chronic HF patients. Noting the variation in proprietary fish oil supplements, and given this trial used high dose n-PUFA (EPA and DHA > 850mg/1g fish oil once daily), supplementation using this dose may be considered as an adjunct to optimised recommended pharmacotherapy (i.e., ACE inhibitor, beta-blocker and MRA therapy) in HFrEF patients.
Iron supplementation for iron deficiency