Angiotensin receptor-neprilysin inhibition in patients with acute decompensated heart failure: an expert consensus position paper

Heart Fail Rev. 2022 Jan;27(1):1-13. doi: 10.1007/s10741-021-10115-8. Epub 2021 May 1.


The short-term mortality and rehospitalization rates after admission for acute heart failure (AHF) remain high, despite the high level of adherence to contemporary practice guidelines. Observational data from non-randomized studies in AHF strongly support the in-hospital administration of oral evidence-based modifying chronic heart failure (HF) medications (i.e., b-blockers, ACE inhibitors, mineralocorticoid receptor antagonists) to reduce morbidity and mortality. Interestingly, a well-designed prospective randomized multicenter study (PIONEER-HF) showed an improved clinical outcome and stress/injury biomarker profile after in-hospital administration of sacubitril/valsartan (sac/val) as compared to enalapril, in hemodynamically stable patients with AHF. However, sac/val implementation during hospitalization remains suboptimal due to the lack of an integrated individualized plan or well-defined appropriateness criteria for transition to oral therapies, an absence of specific guidelines regarding dose selection and the up-titration process, and uncertainty regarding patient eligibility.In the present expert consensus position paper, clinical practical recommendations are proposed, together with an action plan algorithm, to encourage and facilitate sac/val administration during hospitalization after an AHF episode with the aim of improving efficiencies of care and resource utilization.

Keywords: Acute heart failure; Hospitalization; Sacubitril/valsartan.

Publication types

  • Review

MeSH terms

  • Aminobutyrates / therapeutic use
  • Angiotensin Receptor Antagonists / therapeutic use
  • Angiotensins
  • Biphenyl Compounds
  • Consensus
  • Heart Failure* / drug therapy
  • Humans
  • Multicenter Studies as Topic
  • Neprilysin*
  • Prospective Studies
  • Randomized Controlled Trials as Topic
  • Receptors, Angiotensin
  • Stroke Volume
  • Treatment Outcome


  • Aminobutyrates
  • Angiotensin Receptor Antagonists
  • Angiotensins
  • Biphenyl Compounds
  • Receptors, Angiotensin
  • sacubitril
  • Neprilysin