A -year-old man with symptomatic heart failure with reduced ejection fraction (LVEF ) is evaluated in the clinic. He is currently taking lisinopril, metoprolol succinate, and spironolactone. His blood pressure is mmHg, and his heart rate is /min. A basic metabolic panel shows a serum potassium of mEq/L and a serum creatinine of mg/dL. To further optimize his guideline-directed medical therapy, the physician decides to replace lisinopril with sacubitril-valsartan.
Which of the following are required steps in the execution and monitoring of this treatment transition? (Select all that apply)
- Enforce a -hour washout period after the final dose of lisinopril before administering the first dose of sacubitril-valsartanAnswer
- Reassess serum potassium and renal function with a basic metabolic panel to weeks after initiating sacubitril-valsartanAnswer
- CDiscontinue spironolactone prior to the transition to avoid severe, life-threatening hyperkalemia
- DUtilize serial measurements of serum B-type natriuretic peptide (BNP) to evaluate long-term therapeutic efficacy and volume status
- ETemporarily withhold metoprolol succinate for hours during the transition to mitigate the risk of profound synergistic bradycardia
Answer
The required steps are enforcing a 36-hour washout period after the final lisinopril dose before starting sacubitril-valsartan, and reassessing serum potassium and renal function 1 to 2 weeks after initiation.
Sacubitril-valsartan is an angiotensin receptor-neprilysin inhibitor (ARNI) that improves morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). Neprilysin normally degrades vasoactive peptides, including bradykinin. Because ACE inhibitors (like lisinopril) also inhibit bradykinin breakdown, the concurrent use of an ACE inhibitor and an ARNI significantly increases the risk of life-threatening angioedema. Therefore, a strict -hour washout period is mandatory when transitioning from an ACE inhibitor to an ARNI. (Note: this washout is not required when transitioning from an ARB to an ARNI). Additionally, ARNIs can cause renal impairment and hyperkalemia. Because this patient is concurrently taking spironolactone (a potassium-sparing mineralocorticoid receptor antagonist), reassessing serum creatinine and potassium to weeks after initiation is a necessary monitoring step to prevent severe hyperkalemia or acute kidney injury.
Step-by-Step Solution
Key Concept
Monitoring and transitioning protocols for Angiotensin Receptor-Neprilysin Inhibitors (ARNIs) in Heart Failure
Estimated Time:2m 0s