Evaluation of Angiotensin Receptor and Neprlysin Inhibition (ARNI) in Patients of Heart Failure with Reduced Ejection Fraction (HFrEF) - a real-world study

Objectives: This is a real world prospective study to evaluate the effects of Neprlysin Inhibition (ARNI) using sacubitril/valsartan in patients with heart failure with reduced ejection fraction (HFrEF). Methodology: This was an outpatient study on patients of HFrEF (EF<40%) and stable blood pressure after obtaining informed consent. Consecutive patients were enrolled and followed at 6 and 12 weeks. Detailed clinical and echocardiographic examinations were performed on all visits. Biochemistry evaluating ProBNP, renal profile, HbA1C and electrolytes were performed in 24 patients at baseline and follow-up. Results: We enrolled 80 patients, but 63 patients could be followed. Mean age was 53.54±13.32 years and 55% were males. After 12 weeks treatment improvement in NYHA functional class was seen in 66% and improvement by more than one grade in 31% (p<0.01). Pro-BNP reduced from 3552.71±1804.74 at the baseline to 723±930 on the second FU visit (p<0.002).  Structural improvement was seen in 33% of patients. Left ventricular (LV) end-diastolic diameter (EDD) reduced by 3.49 mm and LV end systolic diameter (ESD) by 3.97 mm (p<0.014). Fractional shortening (FS) increased by 2.07% and EF by 3.52 (p<0.01). Patients tolerated the drug well, but most could not tolerate the higher recommended dosage. Renal status, electrolytes, and HbA1C did not alter significantly. Conclusion: Treatment with sacubitril/valsartan in addition to the guideline directed medical therapy (GDMT) resulted in marked reduction in ProBNP, significant improvement in functional class and enhancement of cardiac pumping activity with reduction in LVEDD and LVESD and improvement in FS and EF.