Sacubitril+valsartan for HFrEF

All patients with HFrEF should be treated with a renin-angiotensin system inhibitor. The angiotensin-receptor neprilysin inhibitor (ARNI) sacubitril+valsartan can be considered first line in patients with newly diagnosed HFrEF, or for patients with symptomatic HFrEF despite ACEI (or ARB) and beta-blocker therapy; see also Overview of renin-angiotensin system inhibitors.

For patients with newly diagnosed HFrEF, start with a low dose of sacubitril+valsartan and uptitrate to the highest tolerated dose within the recommended range¹. Aim to achieve the target dose within 2 to 3 months. Use:

For patients with persistent HFrEF despite ACEI (or ARB) and beta-blocker therapy, replace the ACEI (or ARB) with sacubitril+valsartan. Stop the ACEI at least 36 hours before starting sacubitril+valsartan to minimise the risk of angioedema. Combination therapy with an ACEI (or ARB) and sacubitril+valsartan is contraindicated. When switching to sacubitril+valsartan, consider the current dose of ACEI (or ARB) therapy. For a patient switching from high-dose ACEI (or ARB) therapy (eg perindopril arginine 10 mg daily), a suitable regimen is:

A lower starting dose of sacubitril+valsartan is appropriate when switching from a lower dose of an ACEI or ARB.