Introduction: Heart failure still poses great threat to the afflicted patients and enormous burden to our health-care community. Thanks to the ushering of “Angiotensin Receptor Blockade and Neprilysin Inhibitor (ARNI), Entresto®”, we have made further progress by saving one out of 5 of our patients with chronic heart failure in this decade. Current treatment guidelines have suggested the commencement of ARNI in patients with chronic stable heart failure. There is no mention of starting ARNI in the very beginning of the acute phase of heart failure, especially in the patients needing mechanical support. We try to illustrate the clinical picture and implication of ARNI in acute heart failure.
Method: The study was conducted in a 20-bed based cardiovascular intensive care unit of a tertiary-referring center of Taiwan. We enrolled patients of cardiogenic shock, who were put on left ventricular assist device (LVAD) (CentriMag). Those who were dependent on any vasopressors (eg. nor-adrenaline or vasopressin) were excluded. Concurrent usage of inotropes, such as adrenalin, dopamine or dobutamine, would not preclude our application of ARNI and enrollment. The endpoint of this study were: successful weaning of LVAD, cardiovascular death, and the percentage of achieving guideline-suggested target dose of ARNI.
Results: From Jan. 2017 to Jan. 2019., there were 30 patients put on LVAD with CentriMag. Thirteen patients were excluded as their hemodynamics depended on nor-adrenaline. Seventeen patients of 53.1±9.6-year-old were enrolled and 13 of them were successfully rid of LVAD. Four patients succumbed during the support of LVAD, and 3 of them were due to cardiovascular death. Upon enrollment the LVEF was 18±10.1% and NT pro-BNP was 10327±12629 pg/ml. Fifty-three percent of the enrollee could be prescribed with the target dose of 200mg bid Entresto® within 5.1±3.6 days of initiating ARNI, but only 23.5% could tolerate 200mg bid as maintenance. On initiating ARNI, on-going acute kidney injury were taking place in 76.5% of our enrollee, but only 23.5% suffered persistent renal failure, depending on long-term renal replacement therapy. After 27.8±23.0 days of LVAD, the LVEF improved (43.3±23.0%) sufficing the weaning off.
Conclusion: The very beginning of acute heart failure may have the highest surge of neurohormonal bombardment by renin-agiotensin-aldosterone system. Initiating ARNI in this stage, particularly in patients needing mechanical support, may offer some clinical benefit, regardless of initial renal function.