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ACEI remains the Gold Standard

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Dr PK Deb, Kolkata    05 January 2018

  1. As compared to ACEI, ARBs were not found to be superior in reducing all-cause mortality or HF hospitalizations in symptomatic HF (JACC. 2002;39(3):463).
  2. In 2004, controversy surfaced with the reports that ARBs may increase MI and patients need to be told about this (ARB-MI Paradox). A flow of controversial editorials continued to question the safety of ARBs.
  3. Patients intolerant to ACEI due to hyperkalemia, worsening of renal function or hypotension may have a similar response to ARB also.
  4. The PARADIGM study in 2014 introduced angiotensin-neprilysin inhibition, following a fast track mechanism: 2014-study published, 2015: FDA approval, 2016: Guidelines updated to include ARNI.
  5. Questions were raised on the PARADIGM study about the rationale of combining an ARB with a neprilysin inhibitor and not with an ACEI; why was neprilysin inhibitor not used alone; the study design; why was a lower dose of enalapril used in the study; did the impact on efficacy of LCZ696 depend on the patient’s baseline characteristics; effect on renal impairment and the efficacy of LCZ696 on changes in BP and types of HF. The cost-effectiveness and the sponsorship bias also came under scrutiny.
  6. As per ESC 2016 recommendations, ACEI, MRAs and β blockers continue to be standard of care in HF management. Sacubitril/valsartan is recommended as a replacement and not as first-line therapy.
  7. The 2016 ACC/AHA/HFSA focused update on new pharmacological therapy for HF recommend substituting ACEI/ARB with ARNI. Addition of ACEI with LCZ696 would have been a scientific compulsion, but addition of valsartan with LCZ696 is a sponsor’s compulsion. It can be easily concluded that ACEI is the corner stone of HF therapy and is still the Gold Standard.

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