Angiotensin-neprilysin inhibition in acute decompensated heart failure: a meta-analysis of randomized controlled trials.

BACKGROUND: Angiotensin receptor - neprilysin inhibitors (ARNI) are well-established for chronic heart failure (HF) with reduced ejection fraction. However, their efficacy and safety after stabilization of acute decompensation (ADHF) remain unclear. This meta-analysis evaluates ARNI versus angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) post-ADHF. METHODS: Meta-analysis of randomized controlled trials (RCTs) from PubMed, Scopus, WOS, Embase, and CENTRAL up to November 2024. Risk ratios (RR) and standardized mean differences (SMD) with 95% confidence intervals (CI) were used. RESULTS: Three RCTs (1,741 patients) were included. ARNI use after ADHF stabilization significantly reduced HF rehospitalization/all-cause mortality (RR: 0.71; 95% CI: 0.57-0.88; p < 0.01), HF rehospitalization (RR: 0.73; 95% CI: 0.57-0.93; p = 0.01), worsening renal function (RR: 0.80; 95% CI: 0.64-1.00; p = 0.048), and NT-proBNP at 4 weeks (SMD: -0.24; 95% CI: -0.34 to -0.14; p < 0.0001) and 8 weeks (SMD: -0.21; 95% CI: -0.31 to -0.10; p = 0.0001). However, ARNI increased symptomatic hypotension risk (RR: 1.33; 95% CI: 1.04-1.71; p = 0.024). CONCLUSION: initiation of ARNI after ADHF stabilization is more effective than ACEIs/ARBs for cardiovascular and renal outcomes, albeit with higher symptomatic hypotension risk. PROTOCOL REGISTRATION: PROSPERO: CRD42024618027.

Duke Scholars

Author Robert John Mentz Medicine, Cardiology