Effects of sacubitril/valsartan according to background beta-blocker therapy in patients with heart failure and reduced ejection fraction: Insights from PARADIGM-HF

Sharmistha Datta Gupta; Jawad H Butt; Eoghan G M McMurray; Atefeh Talebi; Shingo Matsumoto; Adel R Rizkala; Alasdair D Henderson; Akshay S Desai; Martin Lefkowitz; Milton Packer; Jean L Rouleau; Scott D Solomon; Karl Swedberg; Michael R Zile; Pardeep S Jhund; John J V McMurray; PARADIGM‐HF Investigators and Committees

doi:10.1002/ejhf.3515

Effects of sacubitril/valsartan according to background beta-blocker therapy in patients with heart failure and reduced ejection fraction: Insights from PARADIGM-HF

Eur J Heart Fail. 2024 Nov 19. doi: 10.1002/ejhf.3515. Online ahead of print.

Authors

Sharmistha Datta Gupta¹, Jawad H Butt^{1

2

3}, Eoghan G M McMurray¹, Atefeh Talebi¹, Shingo Matsumoto¹, Adel R Rizkala⁴, Alasdair D Henderson¹, Akshay S Desai⁵, Martin Lefkowitz^{2

4}, Milton Packer⁶, Jean L Rouleau⁷, Scott D Solomon⁵, Karl Swedberg⁸, Michael R Zile^{9

10}, Pardeep S Jhund¹, John J V McMurray¹; PARADIGM‐HF Investigators and Committees

Affiliations

¹ BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
² Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
³ Department of Cardiology, Zealand University Hospital, Roskilde, Denmark.
⁴ Novartis Pharmaceuticals, East Hanover, NJ, USA.
⁵ Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.
⁶ Department of Internal Medicine, University of Texas Southwestern Medical Center.
⁷ Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QB, Canada.
⁸ Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.
⁹ Medical University of South Carolina, Charleston, SC, USA.
¹⁰ Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA.

PMID: 39563094
DOI: 10.1002/ejhf.3515

Abstract

Aims: Beta-blockers may inhibit neprilysin activity and conversely, neprilysin inhibition may have a sympatho-inhibitory action. Consequently, sacubitril/valsartan may have a greater effect in patients not receiving a beta-blocker compared to those treated with a beta-blocker.

Methods and results: We examined the effect of sacubitril/valsartan compared to enalapril on outcomes according to background beta-blocker treatment in the 8399 patients with heart failure with reduced ejection fraction enrolled in PARADIGM-HF. The primary outcome was time to first heart failure hospitalization or cardiovascular death. Compared to the 7811 patients taking a beta-blocker, the 588 patients not receiving a beta-blocker were older, more frequently female, but had a similar mean left ventricular ejection fraction and New York Heart Association class distribution, with little difference in N-terminal pro-B-type natriuretic peptide. Patients not taking beta-blockers had a higher rate of the primary endpoint than those taking beta-blockers. The benefit of sacubitril/valsartan on the primary endpoint was evident in both the no beta-blocker subgroup (hazard ratio [HR] 0.61, 95% confidence interval [CI] 0.45-0.82) and the beta-blocker subgroup (HR 0.82, 95% CI 0.75-0.90; p-interaction = 0.06). The respective HRs for cardiovascular death were 0.47 (95% CI 0.32-0.69) versus 0.84 (95% CI 0.75-0.95; p-interaction <0.01) and for HF hospitalization 0.76 (95% CI 0.51-1.12) versus 0.80 (95% CI 0.71-0.90; p-interaction = 0.73). For all-cause death, the HR in the no beta-blocker group was 0.50 (95% CI 0.36-0.71) compared to 0.89 (95% CI 0.80-0.99) in the beta-blocker group (p-interaction <0.01). Safety outcomes related to sacubitril/valsartan versus enalapril did not differ according to background beta-blocker use.

Conclusion: Sacubitril/valsartan may be more effective than enalapril in reducing the risk of death in patients not treated with a beta-blocker compared to those treated with a beta-blocker, but is effective regardless of beta-blocker use.

Clinical trial registration: ClinicalTrials.gov NCT01035255.

Keywords: Beta‐blocker; Clinical trial; Heart failure with reduced ejection fraction.

Associated data

ClinicalTrials.gov/NCT01035255