Early drop in blood pressure following angiotensin receptor-neprilysin inhibitor initiation in decompensated heart failure

In a large-scale randomized controlled study of heart failure (HF), angiotensin receptor-neprilysin inhibitors (ARNI) reduced cardiovascular events compared to enalapril, but resulted in more symptomatic hypotension. However, changes in blood pressure (BP) during hospitalization in patients with decompensated HF treated with ARNI remain unknown. We retrospectively analyzed BP during hospitalization for decompensated HF in a multi-center registry. Among 166 patients treated with newly prescribed renin-angiotensin system inhibitor (75.7 ± 13.4 years, 57.2% men, and ejection fraction 39 ± 17%), 114 were treated with newly prescribed ARNI (ARNI group) and 52 were treated with newly prescribed angiotensin converting enzyme inhibitors or angiotensin receptor blockers but without ARNI (ACEi/ARB group). The initial day of prescription was day 4 [2-6] for the ARNI group and day 3 [1-6] for the ACEi/ARB group. Three days after the initiation of each drug, systolic BP dropped from 132 ± 24 to 117 ± 19 mmHg (ARNI group, p < 0.001) and 131 ± 19 to 117 ± 21 mmHg (ACEi/ARB group, p < 0.001). A mixed-effects model showed similar BP reductions in both groups (p = 0.247). Herein we showed a downward trend in BP following ARNI initiation in decompensated HF. Early changes in BP after ARNI initiation were comparable with those in the ACEi/ARB group.