Sacubitril/valsartan can improve exercise performance in systolic chronic heart failure patients: a case report

Objective: The cardiopulmonary exercise test (CPET) provides functional prognostic parameters for patients with chronic heart failure (CHF), such as peak volume of oxygen (VO2) and minute ventilation/carbon dioxide production (VE/VCO2) slope. Sacubitril/valsartan (LCZ696) has been recently approved for CHF patients as it reduces cardiovascular (CV) deaths and hospitalization for heart failure (HF). However, the potential beneficial effects of this therapy on exercise performance have been poorly investigated to date.Case presentation: We present a 64 year old woman with systolic HF (New York Heart Association [NYHA] class III, ejection fraction 35%) due to moderate/severe aortic and tricuspid regurgitation and pulmonary hypertension. The patient had several co-morbidities and a history of CV surgery (mitral valve replacement due to bacterial endocarditis). In November 2016, a CPET was performed in stable clinical conditions, showing severe cardiogenic limitation with signs of pulmonary hypertension (peak VO2 46% of predicted, VE/VCO2 slope 36.5). According to current guidelines, an angiotensin-converting enzyme inhibitor was replaced with sacubitril/valsartan (24/26 mg for 2 weeks and then increased to 49/51 mg) without any other change in medical therapy. At 2 months, CPET showed improvement in exercise performance (peak VO2 61%, VE/VCO2 slope 26.9). Echocardiographic parameters also showed mild improvement, whereas renal function remained unchanged. Thus, the dose of sacubitril/valsartan was increased to 97/103 mg.Conclusions: We present a case of a systolic HF patient successfully treated with sacubitril/valsartan who showed a rapid improvement of exercise performance at CPET.