Case Study

Waleed AlHabeeb, MD, MHA Consultant Heart Failure Cardiologist President of the Saudi Heart Failure

Group

• 52 Y/O gentleman

• Familial dilated cardiomyopathy

• Severe LV dysfunction EF 25%

• NYHA class II

• No orthopnea or PND

• BP 100/60 HR 80

• JVP 10cm

• On Valsartan 40mg BID, Bisoprolol 10mg, lasix80mg BID

• Cr 120 K 4.8

• Valsartan increased to 80mg BID K 5.2

• Symptoms and exam the same

Next step in managing this patient would be

A) Reduce valsartan back to 40mg BID

B) Add an aldosterone antagonist

C) Switch Valsartan to Sacubitril/Vasartan

D) Add Ivabradine

E) Refer for advanced therapies (VAD/TX)

F) Do nothing, just observe

A) Reduce valsartan back to 40mg BID

B) Add an aldosterone antagonist

C) Switch Valsartan to Sacubitril/Valsartan

D) Add Ivabradine

E) Refer for advanced therapies (VAD/TX)

F) Do nothing, just observe

Am Heart J 2006;151:444- 50

0

16

32

40

24

8

Enalapril(n=4212)

360 720 10800 180 540 900 1260

Days After Randomization

4187

4212

3922

3883

3663

3579

3018

2922

2257

2123

1544

1488

896

853

249

236

LCZ696

Enalapril

Patients at Risk

1117

Kap

lan

-Meie

r E

sti

mate

of

Cu

mu

lati

ve

Rate

s (

%)

914

LCZ696(n=4187)

HR = 0.80 (0.73-0.87)

P = 0.0000002

Number needed to treat = 21

PARADIGM-HF: Cardiovascular Death or Heart Failure Hospitalization (Primary Endpoint)

N Engl J Med 2014;371:993–1004

*Enalapril 10 mg 2x daily as comparator vs ENTRESTO® 200 mg 2x daily in the PARADIGM-HF study (in addition of standard therapy). ‡Elevated serum creatinine ≥2,5 mg/dL. §Elevated serum potassium >5,5 mmol/l. ¶Angioedema with no treatment or use of antihistamines only.

McMurray et al. N Engl J Med 2014;371:993–1004

20

Pro

po

rtio

n o

f ad

vers

e ev

ents

(%

)

10

5

0Renal impairment‡

11.3

p<0.001

Sacubitril/valsartan (N=4,187)

Enalapril* (N=4,212)

15

Cough Hyperkalemia§ Angioedema¶ Symptomatichypotension

14.3

3.34.5

16.117.3

0.2 0.1

14.0

9.2

p=0.07

p=0.15

p=0.19

p<0.001

FollowupParameter Value

NYHA I

Blood Pressure102/68

Heart Rate72 Bpm

JVP8

Cr96

K4.5

NT-ProBnp1530

MedicationSacubitril/Valsartan 200mg BID

THANK YOU