Sacubitril/Valsartan Use Across Transitions Between Community, Hospital, and Skilled Nursing Facility Settings

Background Sacubitril/valsartan, an angiotensin receptor–neprilysin inhibitor (ARNI), improves outcomes in heart failure (HF) but it is underutilized in hospital and ambulatory settings. Patterns of use in post-hospitalization skilled nursing facilities (SNFs) are unknown. We examined ARNI use among older adults transferred to SNFs following a HF hospitalization to address this knowledge gap. Methods We conducted a retrospective parallel cohort study among older adults hospitalized for HF and discharged to SNFs that contributed data to the Long-Term Care Data Cooperative (LTCDC) or the Veterans Health Administration (VA). ARNI exposure was assessed from 1 year before hospitalization through 100 days after SNF admission. Study periods were June 28, 2017 to October 14, 2024 (LTCDC) and July 7, 2015 to April 17, 2025 (VA). Results Among 187,878 LTCDC and 19,817 VA patients, the mean (SD) age at SNF admission was 80.0 (8.0) and 77.8 (7.9) years, respectively. Overall, 5.4% (10,183/187,878) of LTCDC and 8.0% (1,590/19,817) of VA patients received ARNI. Among patients exposed to ARNI prior to SNF admission, 47.8% (3,562/7,450) of LTCDC and 31.9% (480/1,504) of VA patients were not administered ARNI in the SNF. Conclusion ARNI use is infrequent among older adults discharged to SNFs after HF hospitalization, and discontinuation is common. These findings could reflect personalized care of a population at high risk for adverse events or a missed opportunity to improve outcomes. Future studies are needed to understand drivers of these patterns and the risk-benefit ratio of ARNI in SNFs, which could differ from the general population.