to block sodium reabsorption. Adding a thiazide-like diuretic can often precipitate a brisk diuresis and close monitoring is required to prevent excessive fluid and electrolyte loss (particularly hypokalemia and hyponatremia).
that there was no placebo arm in the PARADIGM-HF trial, and sacubitril/valsartan was being compared to the standard of care enalapril revealing an incremental benefit. PIONEER-HF (Comparison of Sacubitril-Valsartan versus Enalapril on Effect on NT-proBNP in Patients Stabilized from an Acute Heart Failure Episode), a study on in-hospital initiation of sacubitril/valsartan in acute heart failure patients, showed no difference in adverse events when compared to enalapril.19 Current guidelines recommend replacement with ARNI in Class II to III patients tolerating ACE inhibitor or ARB therapy.20 The starting dose of sacubitril/valsartan is dependent on the dose of ACE inhibitor or ARB that the patient tolerates with a target dose of sacubitril/valsartan being 93 mg/107 mg. Recent guidelines suggest that ARNI can be initial therapy for systolic heart failure avoiding the need to transition from an ACE or ARB.
TABLE 76.1 Angiotensin Converting Enzyme Inhibitors and Associated Initial, Maximum (Max), and Randomized Controlled Trial (RCT) Dose
TABLE 76.2 Commonly Used Angiotensin Receptor Blockers and Associated Initial, Maximum (Max), and Randomized Controlled Trial (RCT) Dose