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【論文摘要】Topic 2: Should Sacubitril/ Valsartan Be Prescribed for HFpEF? (Antagonist)
摘要
Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome in which patients have symptom and signs of heart failure with normal or near normal left ventricular ejection fraction. Most patients with HFpEF also display normal LV volumes and evidences of diastolic dysfunction (abnormal pattern of LV filling and elevated filling pressure). The results of clinical trial have demonstrated that neurohumoral antagonist (beta blockers, angiotensin converting enzyme inhibitors and angiotensin receptor blockers) are effective in heart failure with reduced ejection fraction (HFrEF). All the therapies that improve mortality in HFrEF also reverse the LV dilatation in HFrEF. However, patients with HFPEF either have no or minimal LV dilatation. It may the reason that these agents have not been so effective in HFpEF. The new agents, Sacubitril/ Valsartan are recommended for patients with HFrEF. The clinical data of Sacubitril/ Valsartan in HFpEF patients comes from the PARAMOUNT trial. This phase II study randomized 301 chronic HFpEF patients with baseline elevated N-terminal pro B-type NP (NT-proBNP) levels in a double-blind fashion to a 12-week treatment with Sacubitril/ Valsartan or valsartan and evaluated changes in NT-proBNP levels. At 12 weeks, NT-proBNP was significantly reduced in the Sacubitril/ Valsartan group. At 36 weeks, improvements in left atrial size and NYHA functional class were evident in the Sacubitril/ Valsartan -treated group. However, no diastolic dysfunction parameter were analyzed. (ex, E/E') The cost of the treatment with this new agent is likely to represent a barrier to its use in everyday real-life clinical practice. We need stronger evidence to support us to use this new agent. We need evidence about diastolic function and prognosis improved, not only biomarker improved. While awaiting results of trials evaluating Sacubitril/ Valsartan , clinical focus should be directed at effective treatment of congestion, elimination of precipitating factors (e.g. uncontrolled blood pressure or atrial fibrillation), optimal management of inflammation inciting comorbidities, and identification of at-risk patients for preventive cardiovascular risk strategies.