Which therapy may have better efficacy than an ACE inhibitor or an ARB in heart failure?

Which therapy may have better efficacy than an ACE inhibitor or an ARB in heart failure?

• A. ARNi
• B. ACE inhibitors
• C. ARBs
• D. SGLT2 inhibitors

Answer: (A)

The main idea is that combining neprilysin inhibition with angiotensin receptor blockade provides superior outcomes in heart failure with reduced ejection fraction compared with an ACE inhibitor or an ARB alone. Neprilysin normally breaks down natriuretic peptides, so inhibiting it increases these beneficial peptides, promoting vasodilation, natriuresis, and anti-remodeling effects. Coupling this with an ARB blocks the harmful angiotensin II effects, giving a dual attack on the neurohormonal pathways that drive heart failure progression. In the pivotal PARADIGM-HF trial, sacubitril/valsartan reduced cardiovascular death and heart failure hospitalization more than enalapril in symptomatic HFrEF, establishing its superior efficacy over a traditional ACE inhibitor. That’s why guidelines favor switching eligible patients from an ACE inhibitor or ARB to this ARNi. When switching from an ACE inhibitor to an ARNi, a washout period is recommended to reduce angioedema risk. SGLT2 inhibitors also improve heart failure outcomes, but the strongest evidence showing superiority over an ACE inhibitor or ARB specifically points to this combination therapy.

The main idea is that combining neprilysin inhibition with angiotensin receptor blockade provides superior outcomes in heart failure with reduced ejection fraction compared with an ACE inhibitor or an ARB alone. Neprilysin normally breaks down natriuretic peptides, so inhibiting it increases these beneficial peptides, promoting vasodilation, natriuresis, and anti-remodeling effects. Coupling this with an ARB blocks the harmful angiotensin II effects, giving a dual attack on the neurohormonal pathways that drive heart failure progression. In the pivotal PARADIGM-HF trial, sacubitril/valsartan reduced cardiovascular death and heart failure hospitalization more than enalapril in symptomatic HFrEF, establishing its superior efficacy over a traditional ACE inhibitor. That’s why guidelines favor switching eligible patients from an ACE inhibitor or ARB to this ARNi. When switching from an ACE inhibitor to an ARNi, a washout period is recommended to reduce angioedema risk. SGLT2 inhibitors also improve heart failure outcomes, but the strongest evidence showing superiority over an ACE inhibitor or ARB specifically points to this combination therapy.