Efficacy and safety of sacubitril/valsartan by dose level achieved in the PIONEER-HF trial

DD Berg, E Braunwald, AD DeVore, A Lala, SP Pinney… - Heart Failure, 2020 - jacc.org
DD Berg, E Braunwald, AD DeVore, A Lala, SP Pinney, CI Duffy, Y Gurmu, EJ Velazquez
Heart Failure, 2020jacc.org
Objectives This study sought to evaluate the efficacy and safety of sacubitril/valsartan
according to dose level achieved in the PIONEER-HF (Comparison of Sacubitril/Valsartan
Versus Enalapril on Effect on NT-proBNP in Patients Stabilized From an Acute Heart Failure
Episode) trial. Background In patients hospitalized for acute decompensated heart failure
(ADHF), in-hospital initiation and continuation of sacubitril/valsartan as compared with
enalapril is well tolerated, achieves a greater reduction in N-terminal pro–B-type natriuretic …
Objectives
This study sought to evaluate the efficacy and safety of sacubitril/valsartan according to dose level achieved in the PIONEER-HF (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on NT-proBNP in Patients Stabilized From an Acute Heart Failure Episode) trial.
Background
In patients hospitalized for acute decompensated heart failure (ADHF), in-hospital initiation and continuation of sacubitril/valsartan as compared with enalapril is well tolerated, achieves a greater reduction in N-terminal pro–B-type natriuretic peptide (NT-proBNP), and reduces the risk of cardiovascular death or rehospitalization for HF through 8 weeks. However, not all patients achieve the target dose of sacubitril/valsartan, and its efficacy and safety in such patients are of interest.
Methods
PIONEER-HF was a randomized, double-blind, active-controlled trial of sacubitril/valsartan versus enalapril in 881 patients stabilized during hospitalization for ADHF. Blinded study medication was administered for 8 weeks, with initial dosing selected based on the systolic blood pressure at randomization and titrated toward a target of sacubitril/valsartan 97/103 mg twice daily, or enalapril 10 mg twice daily, with an algorithm based on systolic blood pressure and the investigator’s assessment of tolerability.
Results
At 4 weeks, 199 (55%) patients allocated to sacubitril/valsartan and 211 (60%) patients allocated to enalapril were dispensed the target dose. Baseline characteristics were similar in the 2 treatment groups within each dose level. There was no heterogeneity across dose levels in the effect of sacubitril/valsartan on the reduction in NT-proBNP (pinteraction = 0.69), the reduction in cardiovascular death or rehospitalization for heart failure (pinteraction = 0.42), or the pre-specified adverse events of special interest through 8 weeks.
Conclusions
In hemodynamically stabilized patients with ADHF, the efficacy and safety of sacubitril/valsartan are generally consistent across dose levels. (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on NT-proBNP in Patients Stabilized From an Acute Heart Failure Episode [PIONEER-HF]; NCT02554890)
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