Short‐term echocardiographic evaluation by global longitudinal strain in patients with heart failure treated with sacubitril/valsartan

Abstract

Aims The angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan reduces mortality and hospitalizations in patients with heart failure and reduced ejection fraction (HFrEF). Favourable effects on haemodynamic and functional parameters have been observed in patients with HFrEF undergoing ARNI therapy, using standard transthoracic echocardiography. Global longitudinal strain (GLS) assessment uses a semi‐automatic procedure to provide a reliable and repeatable method that improves the detection of early changes of contractile function. We aimed to assess the effects of ARNI on GLS and myocardial mechanics in patients with HFrEF. Methods and results Thirty patients with New York Heart Association class II–III HFrEF were treated with ARNI and monitored using standard echocardiographic examination and GLS measurements at baseline, 3 months, and 6 months. ARNI therapy resulted in a significant reduction of ventricular volumes and a significant increase in left ventricular ejection fraction at 6 months but not 3 months by standard transthoracic echocardiography (left ventricular ejection fraction from 28 ± 8% at baseline to 34 ± 12% at 6 months, P < 0.001). Non‐significant differences in the size of the left atrium, right ventricular function, and pulmonary pressures were found at 6 months. By using GLS, there was a progressive improvement of all strain parameters by 3 months. The improvement showed a progressive trend over time and maintained significance at 6 months: GLS 4ch −7.2 ± 4.8% at baseline vs. −7.5 ± 3.9% at 3 months (P = 0.025) and − 9.2 ± 5.2% at 6 months (P = 0.0001); AVG GLS −6.9 ± 4.3 at baseline vs. −7.9 ± 4.2 at 3 months (P = 0.04) and − 8.8 ± 4.4 at 6 months (P = 0.035); GLS endo 8.2 ± 4.8 at baseline vs. −9.0 ± 4.8 at 3 months (P = 0.05) and − 10.1 ± 5.1 at 6 months (P = 0.001). Conclusions Sacubitril/valsartan induces an early benefit on left ventricular remodelling, which is captured by myocardial strain and not by standard echocardiography. Strain method represents a practical tool to assess early and minimal variations of left ventricular systolic function.

Effects of sacubitril valsartan on clinical and echocardiographic parameters of outpatients with heart failure and reduced ejection fraction

“…Our results confirmed these findings and demonstrated a significant improvement of RWT after SV initiation. In addition, as previously observed [18] , we demonstrated an increase of E/A, which could represent an expression of diastolic function improvement.…”

“…The positive effect on LV diameters, volumes and systo-diastolic performance seems to occur early after treatment initiation, in line with previous data on short term effect of ARNI [16] , [17] , [18] , [19] , [20] . In fact, at 3 months follow-up we observed a global myocardial remodelling with a significative improvement of cardiac function.…”

“…Three clinical studies and a metanalysis showed a further improvement of cardiac reverse remodelling with SV compared to ACEi or ARBs [7] , [8] , [9] , [10] . Other clinical studies confirmed long term [11] , [12] , [13] , [14] , [15] and short term [16] , [17] , [18] , [19] , [20] improvement in left ventricular ejection fraction (LVEF). SV treatment could induce also an improvement in atrial dimensions [7] , [10] , [13] , [14] , [15] , [19] , mitral regurgitation (MR) [9] , [16] , left ventricular mass (LVM) index [8] , [10] , [17] , diastolic function [7] , [15] , [16] , left ventricle end-systolic volume (ESV) [7] , [10] , [13] , [14] , [15] , [16] , [17] , [19] , [20] and end-diastolic volume (EDV) [7] , [9] , [10] , [13] , [15] , [16] , [17] , [19] , [20] , and right ventricle function [14] , [20] .…”

“…Given the impact on hard outcomes showed in the PARADIGM-HF [5] trial, and on the basis of other numerous real-life studies still confirming efficacy and safety performances, the introduction of SV among the treatment options of HFrEF has completely overturned the pharmacological approach to this condition. However, the studies conducted so far did not fully clarify the effects of SV on cardiac function and myocardium reverse remodelling, with results sometimes discordant [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] . Our study analysed the impact of SV therapy on echocardiographic and clinic parameters of HFrEF outpatients previously treated with an optimal individualized pharmacological therapy which included ACEIs or ARBs, BBs and in most patients MRAs.…”

Heart Failure With Mid-range or Recovered Ejection Fraction: Differential Determinants of Transition

“…Many studies have shown improvement in the main echocardiographic parameters in patients with HFrEF after the introduction of ARNI. [ 50 , 51 ] The benefits in terms of prognosis, rehospitalisation and quality of life offered by ARNI suggest that therapy initiated at the maximum tolerated dose, during the HFrEF stage, has to be continued at the same dosage, and should be down-titrated only if acute kidney failure or severe hypotension occur. [ 52 , 53 ] In the Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction (PARAGON-HF) trial, ARNI failed to reduce the primary composite endpoint of total hospitalisations for HF and CV death in patients with HF and LVEF ≥45%.…”