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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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