Effects of sacubitril/valsartan on B-type natriuretic peptide circulating levels and loop diuretic dose in a case series of stabilized heart failure patients with left ventricular ejection fraction ≤35%

Sacubitril/valsartan, an angiotensin receptor neprilysin inhibitor, was shown to improve outcome in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). There are reasons for believing that the concept that the lower the B-type natriuretic peptide (BNP) circulating level the better the prognosis may no longer be correct in patients treated with sacubitril/valsartan, since sacubitril may interfere with BNP clearance. We reported a case series of ten patients with stable chronic HF and LVEF ≤35% (mean age: 64 ± 8 years; 30% female), referred to our outpatient HF clinic, treated with sacubitril/valsartan, in whom the global amelioration of NYHA class and LVEF was coupled with a clinically significant decrease in BNP levels and a reduction of loop diuretic dose. Average sacubitril/valsartan daily dose was 220 mg. The median duration of treatment was 15 months (range: 6-21 months). Seventy percent of patients exhibited an improvement in exercise tolerance, as indicated by the change in NYHA class. There was also an improvement in LVEF from 28 ± 5% to 39 ± 7%. Clinically significant reductions in BNP levels were evident, with a median change from 181 pg/ml to 70 pg/ml. Furosemide daily dose decreased from a median of 43.3 mg to 12.5 mg. This case series suggests that BNP may still be valuable for the assessment of ambulatory HF patients, after the optimization of sacubitril/valsartan therapy.