Physicians' Academy for Cardiovascular Education

Fewer ventricular arrhythmias with angiotensin-neprilysin vs angiotensin inhibition in HF

Effects of angiotensin-neprilysin inhibition as compared to angiotensin inhibition on ventricular arrhythmias in reduced ejection fraction patients under continuous remote monitoring of implantable defibrillator devices.

Literature - de Diego C, González-Torres L, Núñez JM, et al. - Heart Rhythm 2017; published online ahead of print


For HFrEF patients, ACEis, ARBs, MRAs, and beta-blockers (BBKs) are of clinical benefit, whereas the ARNI sacubitril-valsartan decreases morbidity and mortality, including sudden death, with greater efficacy compared to enalapril [1-3]. Data suggest that natriuretic peptide levels, which reflect myocardial wall stress, are independent strong predictors for sustained ventricular arrhythmias and appropriate ICD shocks [4]. It is speculated that various mechanisms, such as ventricular arrhythmias, asystole, electromechanical dissociation, and cardiogenic shock lead to sudden death, however, the precise mechanism of sudden cardiac death remains unclear.

In this study, arrhythmia markers were analyzed with remote monitoring of HFrEF patients with an ICD, for the duration of 9 months under angiotensin inhibition and subsequently for another 9 months under sacubitril-valsartan, in order to evaluate the effect of ARNI on ventricular arrhythmias and appropriate ICD shocks as compared to angiotensin inhibition.

For this purpose, 120 consecutive HFrEF patients with an ICD or ICD-CRT were prospectively recruited (symptomatic HF with NYHA ≥II despite optimal medical therapy, LVEF ≤40%, patient received and tolerated ARNI). The following arrhythmia markers were monitored:

Main results


In HFrEF patients with an ICD under remote control, angiotensin-neprilysin inhibition as compared to angiotensin inhibition alone decreased ventricular arrhythmias, leading to a reduction of appropriate ICD shocks.


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