A Systematic Review on the Use of Sacubitril/Valsartan Initiated Prior to Discharge in Hospitalized Patients With Heart Failure

OBJECTIVE: Systematically review the evidence of sacubitril/valsartan initiated in the hospital setting prior to discharge in patients with acute decompensated heart failure (HF). DATA SOURCES: A literature search using keywords related to sacubitril/valsartan, HF, and inpatient use was performed using MEDLINE, CINAHL, and Google Scholar from inception through May 8, 2020. STUDY SELECTION AND DATA EXTRACTION: Eligible studies included patients initiated on sacubitril/valsartan while inpatient and reported efficacy and safety outcomes. DATA SYNTHESIS: A total of 10 articles were included for study review, of which 9 were full text and 1 was a conference poster. Key outcomes of interest were related to tolerability, N-terminal proB-type natriuretic peptide (NT-proBNP), functional capacity, target dose attainment, or rehospitalization rates. NT-proBNP levels were improved in 4 trials, and the results of functional capacity were mixed based on 2 studies. Rehospitalization rates were reported as secondary outcomes, and only 1 large study showed numerical and statistical improvement. The most frequent dose initiated prior to discharge was sacubitril/valsartan 24/26 mg twice daily. Hypotension was the most commonly reported adverse drug reaction and was commonly cited as a reason for not tolerating inpatient initiation with sacubitril/valsartan therapy. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: Inpatient initiation of sacubitril/valsartan may improve surrogate and clinical outcomes after hemodynamic stabilization. Clinicians should consider patient-specific factors to ensure that benefits outweigh the risks and monitor for hypotension when initiated prior to hospital discharge. CONCLUSION: Initiating inpatient treatment with sacubitril/valsartan after hemodynamic stabilization is reasonable based on available evidence.