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General medicine
Angiotensin– neprilysin inhibitors: should we initiate them in hospital for patients with acute decompensated heart failure?
  1. Sam E. Grigg
  1. Department of Medicine, Austin Health, Heidelberg, Victoria, Australia
  1. Correspondence to Dr Sam E. Grigg, Department of Medicine, Austin Health, Heidelberg, Victoria, Australia; Sam.grigg{at}

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The recent randomised trial PIONEER-HF (Comparison of Sacubitril–Valsartan versus Enalapril on Effect on NT-proBNP in Patients Stabilized from an Acute Heart Failure Episode) investigates the safety and efficacy of in-hospital initiation of angiotensin–neprilysin inhibitors for acute decompensated heart failure. 1

The updated America and European College of Cardiology guidelines endorsed sacubitril–valsartan, an angiotensin–neprilysin inhibitor, as a new therapeutic agent for heart failure with reduced ejection fraction.2 3 These recommendations were based predominantly on the PARADIGM-HF (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial, which demonstrated a significant reduction in death from cardiovascular causes or hospitalisation for heart failure with sacubitril–valsartan (21.8%) versus enalapril (26.5%).4

Despite this, there has been slow uptake of sacubitril–valsartan in clinical practice.5 This reluctance is partially explained by the trial design of PARADIGM-HF,4 which involved stable patients in the outpatient setting on an established dose of ACE inhibitors or angiotensin …

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  • Contributors SEG is the sole contributor of this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.