The Diuretic Potential of Sacubitril/Valsartan: A Tale of 2 Patients.

BACKGROUND: Heart failure prevalence continues to rise in the United States causing significant morbidity and mortality and costing billions in healthcare expenditures. Consensus guidelines updated in 2016 recommend an angiotensin receptor-neprilysin inhibitor (ARNi) as a therapeutic option in lieu of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for the management of stage C heart failure with reduced ejection fraction (HFrEF). For chronic HFrEF patients with New York Heart Association class II or III symptoms tolerating an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, a change in therapy to an ARNi is recommended to further reduce morbidity and mortality.

PURPOSE: We present a brief case series of 2 patients initiated on ARNi therapy for treatment of HFrEF and evaluate their fluid status and diuretic needs before and after ARNi dose optimization.

CONCLUSIONS: After titration to target-dose ARNi therapy, both patients demonstrated improved fluid and electrolyte balance, as well as a reduction in diuretic therapy requirements, suggesting a mechanism of diuresis attributable to ARNi therapy.

CLINICAL IMPLICATIONS: Angiotensin receptor-neprilysin inhibitor therapy seems to promote a clinically relevant diuresis in heart failure patients because of increased levels of functioning natriuretic peptides. Awareness of this diuretic potential may allow for optimization of heart failure regimens with pharmacologic agents demonstrated to improve morbidity and mortality, while preventing adverse effects that may occur with overdiuresis.