Angiotensin Receptor–Neprilysin Inhibition in Acute Myocardial Infarction

SPS commentary:

According to an accompanying editorial, the findings of this study (PARADISE-MI) do not support the use of an angiotensin receptor–neprilysin inhibitor (ARNI) before hospital discharge after an acute MI for which an ACE inhibitor or angiotensin-receptor blocker (ARB) is the guideline-recommended treatment. It notes that even if the hazard ratio had reached significance, event rates in the trial were so low that sacubitril–valsartan (SV) would have to have been given to >100 patients for 22 months to have prevented 1 death from cardiovascular causes or hospitalisation for heart failure. It adds that in outpatients for whom left ventricular ejection fraction remains low, a later switch from an ACE inhibitor or ARB to an ARNI is reasonable if blood pressure and medication coverage are robust. It suggests that reserving SV for these outpatients could potentially lower the number needed to treat with an ARNI to 21 patients for 27 months to prevent one event, as in PARADIGM-HF; and for patients recovering a normal ejection fraction after MI, ACE inhibitors and ARBs remain the recommended renin–angiotensin–aldosterone system inhibitors. Furthermore, although data are lacking for patients who have a normal ejection fraction after MI and no diagnosis of heart failure, it notes PARAGON-HF did not show a benefit of SV over valsartan alone for patients with a normal ejection fraction and heart failure diagnosis, 34% of whom had a history of ischaemic events. It concludes that this current study “represents yet another important contribution by the researchers to the dynamic topography of heart failure, which is still shaped by ACE inhibitors and ARBs. As exploration into newer therapies continues, we recognize our responsibilities to draw the maps that define them.”