Real-world Practical Experience of Angiotensin Receptor-neprilysin Inhibitor in Older Japanese Patients with Chronic Heart Failure

Toshinori Komatsu; Masatoshi Minamisawa; Ayako Okada; Hirohiko Motoki; Toshio Kasai; Koichiro Kuwahara; Uichi Ikeda

doi:10.31662/jmaj.2023-0109

Real-world Practical Experience of Angiotensin Receptor-neprilysin Inhibitor in Older Japanese Patients with Chronic Heart Failure

JMA J. 2023 Oct 16;6(4):489-498. doi: 10.31662/jmaj.2023-0109. Epub 2023 Sep 27.

Authors

Toshinori Komatsu^{1

2}, Masatoshi Minamisawa¹, Ayako Okada¹, Hirohiko Motoki¹, Toshio Kasai², Koichiro Kuwahara¹, Uichi Ikeda²

Affiliations

¹ Department of Cardiology, Shinshu University School of Medicine, Nagano, Japan.
² Department of Cardiology, Nagano Municipal Hospital, Nagano, Japan.

Abstract

Introduction: Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), is superior to enalapril for chronic heart failure (CHF) with reduced ejection fraction (EF). However, its efficacy and safety in older Japanese patients in clinical practice are poorly understood. We aimed to investigate the efficacy and safety of ARNI compared with angiotensin receptor blocker (ARB) in older patients with CHF in real-world clinical practice. In addition, nutritional status and body composition were investigated as essential indicators of efficacy.

Methods: This retrospective single-center observational study enrolled 55 consecutive older patients (aged ≥75 years) with CHF who received ARNI (n = 27) or ARB (n = 28) therapy between October 2020 and March 2021. Blood samples were collected before (baseline) and 4, 12, and 24 weeks after ARNI or ARB therapy initiation. Furthermore, echocardiography was performed before (baseline) and 24 weeks after ARNI or ARB therapy initiation. The efficacy endpoints were changes in N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, left ventricular EF, nutritional status, and body composition changes. The controlling nutritional status (CONUT) score and geriatric nutritional risk index were investigated as nutritional status indices. The safety endpoints were symptomatic hypotension, renal function exacerbation, and hyperkalemia in patients who continued ARNI or ARB therapy for >24 weeks without additional nonpharmacological treatment.

Results: There were no significant changes in NT-proBNP levels and estimated glomerular filtration rates; however, there was a significant CONUT score improvement in the ARNI group (least-squares mean difference, -1.0; 95% confidence interval, -1.4 to -0.3; p = 0.04). The initial ARNI dose could not be uptitrated in five patients (19%) due to hypotension.

Conclusions: ARNI exhibited significant improvement in the nutritional status in older patients with CHF compared with ARB. However, the ARNI dose should be adjusted according to the patient's blood pressure.

Keywords: CONUT score; angiotensin receptor blocker; chronic heart failure; older Japanese patients; sacubitril/valsartan.