Practical considerations on the introduction of sacubitril/valsartan in clinical practice: Current evidence and early experience

Health-related quality of life in patients with heart failure eligible for treatment with sacubitril-valsartan

Aim

To describe and compare self-reported health-related quality of life between younger and older patients with severe heart failure eligible for treatment with sacubitril-valsartan and to explore the association between health-related quality of life and age, NYHA classification, systolic blood pressure and NT-proBNP level.

Design

Cross-sectional study.

Methods

A total of 59 patients, eligible for treatment with sacubitril-valsartan were consecutively included and divided into a younger (≤75 years) and older group (>75 years). Health-related quality of life was assessed using the Kansas City Cardiomyopathy Questionnaire and the EuroQol 5-dimensions. Data were collected between June 2016 and January 2018. The STROBE checklist was used.

Results

There were no differences in overall health-related quality of life between the age groups. The older patients reported lower scores in two domains measured with the Kansas City Cardiomyopathy Questionnaire, namely self-efficacy (67.0 SD 22.1 vs. 78.8 SD 19.7) and physical limitation (75.6 SD 19.0 vs. 86.3 SD 14.4). Higher NYHA class was independently associated with lower Kansas City Cardiomyopathy Questionnaire Overall Summary Score.

Defining the role of peritoneal dialysis in management of congestive heart failure

Introduction: Congestion is an integral component of heart failure (HF) pathophysiology and portends an adverse impact on outcome. Peritoneal dialysis (PD) is a home-based therapeutic modality that has been used in the setting of refractory congestive HF to help optimize volume status. Not only does PD allow for customized sodium and water removal, but it also provides the opportunity for the patients to fully benefit from guideline-directed medical therapy for HF that could have otherwise been challenging to use. Areas covered: Authors provide an overview of the pathophysiologic basis for the use of PD in HF, followed by a review of the findings of the main clinical trials such as the salutary impact on HF re-admissions and quality of life. Since the goals of therapy in this setting differ from those for patients with end-stage renal disease, pertinent practical considerations in the use of this modality are then discussed as well as potential barriers. Expert opinion: For patients with chronic refractory HF, PD represents an alternative to medical therapy alone. Identification of patients that would benefit most from this modality and detection of major enablers and obstacles for the implementation of this therapy should be the focus of future studies.

Management of a Multicomorbid Patient with Heart Failure

The optimal use of sacubitril/valsartan in clinical practice needs further investigation, in particular for patients with multiple comorbidities, as such patients are usually poorly represented in clinical trials. To this end, well-documented case reports may add further evidence to the bulk of “field practice” experience on sacubitril/valsartan. We report here the case of a patient with heart failure with reduced ejection refraction with multiple comorbidities treated with sacubitril/valsartan. Overall, sacubitril/valsartan led to a prompt (within a few months) improvement in LVEF (+15%, from 38 to 53%), without any noticeable adverse events. This therapy also allowed the patient to discontinue furosemide.

Sacubitril/Valsartan in Clinical Practice: A Report of 2 Cases

Following the results of the PARADIGM-HF trial, the European Society of Cardiology (ESC) guidelines recommend sacubitril/valsartan to replace ACE inhibitors in ambulatory patients with heart failure with reduced ejection fraction (HFrEF) who remain symptomatic despite optimal therapy and who fit trial criteria. However, the optimal use of sacubitril/valsartan in clinical practice needs further investigation. We report here the cases of 2 patients with HFrEH successfully treated with sacubitril/valsartan in our daily practice. Both subjects presented multiple comorbidities and received an implantable cardioverter defibrillator in primary prevention. In both patients, therapy with sacubitril/valsartan led to prompt (30 days) amelioration of heart function, with a corresponding decrease in NHYA class and without any relevant safety issue.

Fluid overload as a major target in management of cardiorenal syndrome: Implications for the practice of peritoneal dialysis

Congestion is an integral component of cardiorenal syndrome and portends an adverse impact on the outcomes. Recent studies suggest that congestion has the ability of modulating the interactions between the kidney and the heart in this setting. Peritoneal dialysis (PD) is a home-based therapeutic modality that is not only offered to patients with end-stage renal disease to provide solute clearance and ultrafiltration, but it has also been used in patients with refractory heart failure and fluid overload to help optimize volume status. Several uncontrolled studies and case series have so far evaluated the role of PD in management of hypervolemia for patients with heart failure. They have generally reported favorable results in this setting. However, the data on the outcomes of patients with end-stage renal disease and concomitant heart failure is mixed, and the proposed theoretical advantages of PD might not translate into improved clinical endpoints. Congestion is prevalent in this patient population and has a significant effect on their survival. As studies suggest that a significant subset of patients with end-stage renal disease who receive PD therapy are hypervolemic, suboptimal management of congestion could at least in part explain these conflicting results. PD is a highly flexible therapeutic modality and the choice of techniques, regimens, and solutions can affect its ability for optimization of fluid status. This article provides an overview of the currently available data on the role and clinical relevance of congestion in patients with cardiorenal syndrome and reviews potential options to enhance decongestion in these patients.