Early Initiation of Sacubitril/Valsartan in Intracerebral Hemorrhage With Refractory Hypertension and Chronic Heart Failure: A Case Report

Intracerebral hemorrhage (ICH) is a devastating type of stroke associated with high mortality and morbidity, and its management becomes more challenging when complicated by severe comorbidities such as chronic heart failure. Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor, was originally developed for chronic heart failure but has also demonstrated potent blood pressure-lowering effects. In Japan, sacubitril/valsartan has had an approved indication for hypertension, supported by multiple clinical trials, including the phase III study. However, its application in the acute management of ICH remains extremely limited. We report the case of a man in his 50s with right putaminal hemorrhage complicated by refractory hypertension and chronic heart failure. On admission, his blood pressure remained elevated despite continuous intravenous nicardipine infusion at 11 mg/h and additional nitroglycerin. He subsequently required a combination of five antihypertensive agents. Following surgical evacuation of the hematoma, we transitioned his therapy to oral agents on day two. By initiating and rapidly titrating sacubitril/valsartan, we achieved effective blood pressure control without causing hypotension. In addition, the patient's significantly elevated N-terminal pro-B-type natriuretic peptide level decreased from 1823 to 272 pg/mL, accompanied by dramatic improvements in cardiac size and pulmonary congestion. The clinical course suggests that sacubitril/valsartan offers a unique dual benefit in this high-risk patient population: it not only provides effective blood pressure control but also delivers crucial cardioprotective effects. This report highlights its potential as a game-changing therapeutic option, particularly during the critical transition from intravenous to oral therapy in acute ICH.