Heart Failure

Chronic Condition Management

Tip of the Month

Message from the Medical Director

This month we cover considerations for prescribing Angiotensin Receptor Neprilysin Inhibitors (ARNIs) in patients with heart failure. Read on for information on prescribing, dosing guidelines, and contraindications & cautions before initiating medications sacubitril/valsartan to treat chronic heart failure. For more guidelines, I encourage you to read Mount Sinai's Heart Failure Ambulatory Care Pathway.

I also extend an invitation for you to join me and your clinical colleagues at our upcoming September 12 CME event, Caring for Patients with Complex Chronic Disease: Key Components and Updates to Diabetes & CKD Management. I hope to see you there!

Thank you for your commitment to delivering high-quality care to our patients and in support of their health.

Kind regards,

X. Shirley Chen, MD, MS

In this Issue

ARNIs in heart failure
Considerations for prescribing and dosing
Sacubitril/Valsartan Starting and Target Doses
Contraindications and cautions for sacubitril/valsartan

*MSHP Care Management prioritizes patients in our MSSP and Healthfirst contracts and those patients with Medicaid

Angiotensin Receptor Neprilysin Inhibitors (ARNIs)

in Heart Failure

Consider prescribing Angiotensin Receptor Neprilysin Inhibitors (ARNIs) in patients with heart failure. The AHA recommends starting patients with HFrEF on ARNIs as a first line of treatment and should also be considered for HFmrEF and HFpEF patients, when clinically appropriate.

HF Categorization	LVEF	ARNi Medication Class
HFrEF	LVEF <40%	Class 1 (Strong)
HFmrEF	LVEF 41-49%	Class 2a (Moderate)
HFpEF	LVEF >50%	Class 2b (Weak)

Guideline Directed Medication Therapy across Heart Failure Stages

View this visual algorithm of evidence-based medication therapy for heart failure patients.

Source

Considerations for prescribing and dosing

Before initiating ARNIs, stop any ARB and ACEI medications. For patients on ACEI, allow a 36 hour washout period to reduce the risk of angioedema.

Convert to the appropriate ARNI dose according to the previous ARB or ACEI dose. For patients not previously on ACEI or ARB, start at the lowest dose sacubitril 24 mg/valsartan 26 mg twice per day

Double the dose every 2 to 4 weeks as tolerated, up to a target dose of sacubitril 97 mg/valsartan 103 mg twice per day. Monitor blood pressure, electrolytes, and renal function during titration.

Use cautiously if eGFR <30 mL/minute/1.73 m2

Note: The use of ARNIs as first line agents applies to patients with HFrEF. For patients with co-existing HTN and HFpEF, first line agents can be ACEi or ARB.

Sacubitril/Valsartan

Starting and Target Doses

Starting dose for patients

Not previously on ACEI/ARB

On low-medium dose ACEI:

Enalapril ≤10 mg total daily dose or equivalent dose of another ACEI

On low-medium dose ARB:

Valsartan ≤160 mg total daily dose or equivalent dose of another ARB

Age >75 years old

24mg/26mg twice daily

On high dose ACEI

Enalapril >10 mg total daily dose or equivalent dose of another ACEI

On high dose ARB

Valsartan >160 mg total daily dose or equivalent dose of another ARB

51mg/80mg twice daily

Target dose for all patients if tolerated

97mg/103mg twice daily

Contraindications and cautions for sacubitril/valsartan

Contraindications

Within 36 hours of ACEI use
History of angiodema with or without an ACEI or ARB
Pregnancy
Lactation (no data)
Severe hepatic impairment (Child-Pugh C)
Concomitant aliskiren use in patients with diabetes
Known hypersensitivity to either ARBs or ARNIs

Use with caution in patients with

Severe renal impairment (eGFR<30mL/min/1.73 m2):

Start at lowest dose: 24 mg/26 mg twice daily; double the dose every 2-4 weeks to target maintenance dose of 97 mg/103 mg twice daily as tolerated

Moderate hepatic impairment (Child-Pugh B):

Start at lowest dose: 24 mg/26 mg twice daily; double the dose every 2-4 weeks to target maintenance dose of 97 mg/103 mg twice daily as tolerated

Other indications for caution

Renal artery stenosis
Systolic blood pressure <100 mmHg
Volume depletion

Condition Management CME Course

Caring for Patients with Complex Chronic Disease: Key Components and Updates to Diabetes & CKD Management

Tuesday, September 12

6:00 – 7:30 pm | Live via Zoom

Find more on the Chronic Condition Management Hub

Mount Sinai Health System's Chronic Condition Management Hub is an online resource center for primary care physicians, specialists, and other care providers with resources and information to help them manage chronic health conditions

P: 877-234-6667

E: MSHP@mountsinai.org

Provider Engagement Team