LOS ANGELES—A preponderance of evidence supports the use of sacubitril/valsartan, the first angiotensin II receptor blocker-neprilysin inhibitor-for mortality reduction in patients with heart failure, but the medication remains underprescribed, according to new research.

The objective of a study in Pharmacotherapy was to evaluate eligibility for initiation of sacubitril/valsartan treatment in patients with HF within the largest VA healthcare system in the United States. The cross-sectional study was conducted by VA Greater Los Angeles Healthcare System researchers and colleagues.

Included were 2,985 patients with a HF diagnosis who were alive as of Nov. 1, 2017. Eligibility for sacubitril/valsartan initiation was based on inclusion and exclusion criteria from the Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor with Angiotensin-Converting-Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure, or PARADIGM-HF, trial and the VA Criteria for Use.

The study team estimated the proportion of eligible patients and compared characteristics of eligible patients with those in the PARADIGM-HF trial.

Of the participants, 965 (32.3%) had HF with reduced ejection fraction. Of the patients with HFrEF, 263 (27.3%) met eligibility criteria and were considered candidates for sacubitril/valsartan initiation.

Of the 702 patients who did not fulfill eligibility criteria, researchers explained that the most common reasons were New York Heart Association functional Class I (35.3%) and B-type natriuretic peptide level of 100 pg/mL or lower (22.2%).

Compared with patients in the PARADIGM-HF trial, VA patients were older (70.4 vs. 63.8 years old) and more likely to be male (98.5% vs. 79.0%). In addition, a higher proportion had NYHA functional Class III symptoms (35.4% vs. 23.1%).

The study team determined that, of the 965 patients with HFrEF, 34 (3.5%) had an active sacubitril/valsartan prescription as of Nov. 1, 2017, of whom 27 (79.4%) actually did not meet criteria.

“Whereas 27% of patients with HFrEF were eligible to initiate sacubitril/valsartan, only 3.5% of these patients were prescribed the medication,” the study authors concluded. “Although sacubitril/valsartan reduced morbidity and mortality in clinical trials, it remains underused within this VA healthcare system. This analysis provides important insights into the VA and other healthcare systems regarding the opportunity for optimizing guideline-directed HF therapy.”

1. Han J, Chung F, Nguyen QL, Vaghaiwalla Mody F, Jackevicius CA. Evaluation of Patients with Heart Failure To Determine Eligibility for Treatment with Sacubitril/Valsartan: Insights from a Veterans Administration Healthcare System. Pharmacotherapy. 2019 Sep 9. doi: 10.1002/phar.2328. [Epub ahead of print] PubMed PMID: 31498903.