By Harold L. Karpman, MD, FACC, FACP

Clinical Professor of Medicine, David Geffen School of Medicine at UCLA

Dr. Karpman reports no financial relationships relevant to this field of study.

SYNOPSIS: Compared with enalapril, treatment with sacubitril/valsartan is more effective in reducing 30-day readmissions for any cause following discharge from congestive heart failure hospitalization.

SOURCE: Desai AS, Claggett BL, Packer M, et al. Influence of sacubitril/valsartan on 30-day readmission after heart failure hospitalization. J Am Coll Cardiol 2016;68:241-248.

Despite the development of effective medical therapy for the treatment of patients who experience congestive heart failure (CHF), such patients remain at high risk for recurrent rehospitalization within 30 days of discharge, and nearly 50% of patients are readmitted within six months.1,2 Since 2010, U.S. hospitals with higher-than-expected risk-standardized readmission rates at 30 days are at risk for substantial financial penalties as part of the Hospital Readmissions Reduction Program. Therefore, economists and clinicians alike welcome any therapeutic approach to reducing readmission rates.

The effect of the angiotensin receptor neprilysin inhibitor sacubitril/valsartan on CHF hospital admission rates was compared to enalapril in the PARADIGM-HF trial. In this randomized, double-blind, prospective comparison study, subjects suffering from chronic CHF and presenting with an ejection fraction of < 40% (subsequently lowered to < 35%) received twice-daily drug therapy.4 Researchers randomized 8,399 participants. Rates of hospital readmission were 17.8% in the sacubitril/valsartan group, compared with 21% in enalapril-assigned subjects.3

COMMENTARY

Nearly one in five CHF hospitalization events during the trial was followed by a repeat hospitalization within 30 days, of which more than 50% were related to recurrent CHF. Although the mechanisms by which neprilysin inhibition may facilitate readmission reduction early after discharge following CHF hospitalization remains unclear, the findings further support the potential benefits of sacubitril/valsartan on slowing the clinical progression of patients suffering from CHF after hospital discharge.

While the study results suggested that sacubitril/valsartan-treated patients experienced fewer any-cause readmission hospitalizations than the enalapril group, the data require more detailed analysis before drawing final conclusions. Additionally, the mechanisms by which neprilysin inhibition may facilitate reduction in the readmission rates early after CHF hospitalization remain unclear. However, the data further support the potential benefits of this approach on slowing the clinical progression of patients surviving a CHF hospitalization. As the authors said, the apparent differences in readmission rates noted in the analysis could be attributed to clinical differences between the two treatment groups of patients who were hospitalized.

Desai et al suggested that the data demonstrating fewer all-cause and heart failure readmissions at 30 days in CHF patients with reduced ejection fraction following treatment with sacubitril/valsartan (compared to enalapril) provide additional rationale for the use of the drug combination not only in hospitalized patients but also in patients suffering from chronic, symptomatic CHF with reduced ejection fraction.

REFERENCES

  1. Heidenreich PA, Sahay A, Kapoor JR, et al. Divergent trends in survival and readmission following a hospitalization for heart failure in the Veterans Affairs healthcare system 2002 to 2006. J Am Coll Cardiol 2010; 56:362-368.
  2. Chen J, Ross JS, Carlson MD, et al. Skilled nursing facility referral and hospital readmission rates after heart failure or myocardial infarction. Am J Med 2012;125:100.e1-9
  3. McMurray JJ, Packer M, Desai AS, et al, for the PARADIGM-HF investigators and committees. Angiotensin-neprilysin inhibition versus enalapril in heart failure. N Engl J Med 2014; 371:993-1004.
  4. Desai AS, Claggett BL, Packer M, et al. Influence of sacubitril/valsartan on 30-day readmission after heart failure hospitalization. J Am Coll Cardiol 2016;68:241-248.