Deciding Whether to Take Sacubitril/Valsartan: How Cardiologists and Patients Discuss Out-of-Pocket Costs

J Am Heart Assoc. 2023 Apr 4;12(7):e028278. doi: 10.1161/JAHA.122.028278. Epub 2023 Mar 28.


Background Out-of-pocket costs have significant implications for patients with heart failure and should ideally be incorporated into shared decision-making for clinical care. High out-of-pocket cost is one potential reason for the slow uptake of newer guideline-directed medical therapies for heart failure with reduced ejection fraction. This study aims to characterize patient-cardiologist discussions involving out-of-pocket costs associated with sacubitril/valsartan during the early postapproval period. Methods and Results We conducted content analysis on 222 deidentified transcripts of audio-recorded outpatient encounters taking place between 2015 and 2018 in which cardiologists (n=16) and their patients discussed whether to initiate, continue, or discontinue sacubitril/valsartan. In the 222 included encounters, 100 (45%) contained discussions about cost. Cost was discussed in a variety of contexts: when sacubitril/valsartan was initiated, not initiated, continued, and discontinued. Of the 97 cost conversations analyzed, the majority involved isolated discussions about insurance coverage (64/97 encounters; 66%) and few addressed specific out-of-pocket costs or affordability (28/97 encounters; 29%). Discussion of free samples of sacubitril/valsartan was common (52/97 encounters; 54%), often with no discussion of a longer-term plan for addressing cost. Conclusions Although cost conversations were somewhat common in patient-cardiologist encounters in which sacubitril/valsartan was discussed, these conversations were generally superficial, rarely addressing affordability or cost-value judgments. Cardiologists frequently provided patients with a course of free sacubitril/valsartan samples without a plan to address the cost after the samples ran out.

Keywords: heart failure; sacubitril/valsartan; shared decision‐making.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Angiotensin Receptor Antagonists / therapeutic use
  • Biphenyl Compounds / therapeutic use
  • Cardiologists*
  • Cost-Benefit Analysis
  • Drug Combinations
  • Health Expenditures
  • Heart Failure* / drug therapy
  • Humans
  • Stroke Volume
  • Tetrazoles / therapeutic use
  • Valsartan / therapeutic use


  • sacubitril
  • Tetrazoles
  • Valsartan
  • Biphenyl Compounds
  • Drug Combinations
  • Angiotensin Receptor Antagonists