Sacubitril/Valsartan: Why ARNI Has Replaced ACE Inhibitors as First-Line Therapy

The Sgarbossa criteria identify acute myocardial infarction in the presence of a left bundle branch block, where it is otherwise difficult to tell whether ECG changes represent an acute MI or simply the LBBB pattern — specifically, 4mm or more of ST elevation discordant to the QRS is considered an acute MI regardless of the LBBB. This is used specifically in the context of chest pain with LBBB, not in the context of established heart failure management.

A failing heart relies on two compensatory mechanisms: increased heart rate and elevated blood pressure. A beta blocker reduces both, so cardiac output falls initially and the patient feels rough — but only for the first one to two weeks. After that, sustained reduction in neurohormonal activation reverses adverse cardiac remodelling and the patient improves steadily. Always counsel patients about this dip in advance and reassure them it will get better; a heart failure nurse is an excellent resource for this kind of communication.

BNP and NT-proBNP are released in response to myocardial wall stress, so a normal BNP with a normal ECG makes acute heart failure very unlikely as the cause of a patient's breathlessness — the dyspnoea is most likely pulmonary or another non-cardiac cause. One nuance: in a patient presenting late, days after the onset of acute heart failure while partially compensating, BNP can occasionally read lower than expected, so very recent-onset context still matters.

This is congestive cardiac failure — combined right and left heart failure — and the patient should ideally be hospitalised for close monitoring of renal function and electrolytes. For NYHA class 3 or 4 patients like this, we now routinely add acetazolamide alongside loop diuretics, which improves diuresis and speeds resolution of congestion as long as renal function isn't severely impaired. If blood pressure is low, low-dose renal-dose dopamine in addition to diuretics can help significantly, particularly with right heart failure and valvular dysfunction. Given the liver cirrhosis, use a higher dose of spironolactone, since it also acts on hepatic ascites, and monitor hepatorenal function closely.

The mechanism is glycosuria, which is a nidus for genitourinary infections — balanitis in men and UTIs in women, at an incidence of around 5 to 6%. Counsel every patient on personal and perineal hygiene when starting the drug. If a genitourinary infection develops, get a urine culture, and if confirmed, hold the SGLT2 inhibitor until it resolves, then restart with reinforced hygiene counselling.

Spanning patients from India, Africa, China and Europe, it found significantly reduced all-cause and cardiovascular mortality, a lower risk of sudden cardiac death, a lower risk of worsening heart failure, and survival extended by two years compared with enalapril.

No. The trial evidence is strong enough that a direct start on sacubitril/valsartan, without first trialling an ACE inhibitor, is now standard practice.

At least 36 hours. Concurrent use of both drugs significantly raises the risk of angioedema.

A common approach is to start at half the standard dose, 25 mg twice daily rather than 50 mg, then review at one week with blood pressure and creatinine checks before escalating to the full dose.

Anyone with a prior history of angioedema. The drug is contraindicated in that group.