Sacubitril/Valsartan Underutilization in Skilled Nursing Facilities after a Heart Failure Hospitalization

Presenter: Kelsey Corcoran

Sacubitril/valsartan improves outcomes in heart failure but remains underused, particularly in skilled nursing facilities (SNFs), where many older adults are discharged after hospitalization. This retrospective cohort study evaluated S/V exposure among patients hospitalized for heart failure and discharged to SNFs using data from the Long-Term Care Data Cooperative (LTCDC) and the Veterans Health Administration (VA), assessing use from 1 year before hospitalization through 100 days after SNF admission.

Among 187,878 LTCDC and 19,817 VA patients, only 5.4% and 8.0%, respectively, were exposed to S/V at any time. Among those on S/V prior to hospitalization, discontinuation during SNF stay was common, with 1 in 2 LTCDC patients and 1 in 3 VA patients not receiving S/V. As a result, S/V use at SNF discharge was low at 3.4% in LTCDC and 4.9% in VA cohorts.

These findings highlight very low use and frequent discontinuation of sacubitril/valsartan in SNFs, suggesting underuse of guideline-directed therapy and emphasizing the need to optimize heart failure management in this high-risk population.

Initial Diuretic Dosing in Patients Admitted from the Emergency Department with Acute Decompensated Heart Failure

Presenter: Pranoy Sangowdar

Diuretics are a key therapy in acute decompensated heart failure (ADHF), but dosing practices in the emergency department (ED) prior to admission are not well characterized. This study analyzed 2,216 adults admitted with ADHF across 14 EDs (2017–2019), categorizing initial ED diuretic dosing relative to home dose (no dose, lower/equivalent, or greater-than-home), with outcomes including hospital length of stay (LOS), acute kidney injury (AKI), mortality, and readmission.

Of the cohort, 38.4% (838 patients) received no diuretic, 18.2% (406 patients) received lower or equivalent doses, and 43.9% (972 patients) received greater-than-home doses. Compared to no diuretic, greater-than-home dosing was associated with shorter LOS (95% CI: −0.081 to −0.546 days; p<0.005), greater weight reduction (−0.014 kg/hr; p=0.0286), and lower subsequent diuretic requirements (p<0.001), but a higher risk of AKI (RR 1.37; p<0.001). No differences were observed in in-hospital mortality or 30-day readmission.

A significant proportion of patients hospitalized with ADHF do not receive timely diuretics in the ED, contributing to longer LOS and higher AKI risk.  Optimizing the timing and dosing of diuretic initiation offers a clear opportunity to improve outcomes.

Effects of Sacubitril-Valsartan in Women Compared with Men with Heart Failure and Preserved Ejection Fraction: A Systematic Review and Meta-Analysis

Presenter: Ana Ramos

Heart failure with preserved ejection fraction (HFpEF) accounts for a substantial proportion of heart failure cases and is more common in women, but whether responses to sacubitril/valsartan differ by sex remains unclear. This meta-analysis systematically reviewed studies pooling sex-specific outcomes using a random-effects model. A total of three studies including 7,782 patients were analyzed, of whom 3,486 (44.7%) received sacubitril/valsartan and 50.4% were women, with follow-up ranging from 7.9 to 35.4 months.

Women treated with sacubitril/valsartan showed a significant reduction in the composite of heart failure hospitalization and cardiovascular death (RR 0.77; 95% CI 0.7–0.8; p<0.01), as well as cardiovascular death alone (RR 0.34; 95% CI 0.1–0.8; p=0.02), hyperkalemia (RR 0.78; 95% CI 0.6–0.9; p<0.01), and renal dysfunction (RR 0.61; 95% CI 0.4–0.9; p=0.02) compared to men. However, women had a higher risk of hypotension (RR 1.37; 95% CI 1.1–1.6; p<0.01), and no significant sex-related difference was observed for heart failure hospitalization alone (RR 1.03; 95% CI 0.8–1.3; p=0.79).

These findings suggest that women with HFpEF may derive greater benefit from sacubitril/valsartan in terms of cardiovascular outcomes and safety, although with an increased risk of hypotension.

Not One-Size-Fits-All: Racial/Ethnic Variation in Empagliflozin vs Dapagliflozin Outcomes

Presenter: Feehaan Habib Sultan

Empagliflozin and dapagliflozin are both effective SGLT2 inhibitors for cardiovascular and renal outcomes, although cost differences may influence real-world use. This retrospective analysis included new adult users of either drug with at least one year of follow-up. After applying exclusion criteria and 1:1 propensity score matching, outcomes including all-cause mortality, acute kidney injury, heart failure, myocardial infarction, stroke, hyperkalemia, hospital readmission, and arrhythmia were compared across racial and ethnic subgroups using risk differences.

No significant differences were observed between the two drugs in Hispanic and Pacific Islander patients. Among non-Hispanic Asian patients, a difference was seen only for all-cause mortality (RD +2.1% with empagliflozin). In non-Hispanic White patients, dapagliflozin was associated with higher risks of all-cause mortality (RD +0.8%), myocardial infarction (+0.4%), acute kidney injury (+2%), arrhythmia (+2.5%), and hospital readmission (+6.8%). In non-Hispanic Black patients, dapagliflozin showed higher risks of myocardial infarction (+1.5%), acute heart failure (+1.3%), stroke (+0.9%), acute kidney injury (+2.1%), and hyperkalemia (+1.2%), while empagliflozin had higher readmission risk (+2.1%). In non-Hispanic Native American patients, a significant difference was observed only for myocardial infarction (RD +23.8% with empagliflozin).

These findings demonstrate variability in outcomes between empagliflozin and dapagliflozin across racial and ethnic groups, suggesting that treatment decisions may benefit from a more individualized approach beyond overall efficacy estimates.

Impact of Sacubitril/Valsartan on Anemia in Heart Failure: A Systematic Review and Meta-Analysis

Presenter: Anim Asif

Anemia is common in heart failure and is associated with worse outcomes. This systematic review and meta-analysis evaluated the effect of sacubitril/valsartan on hemoglobin levels and the risk of new-onset anemia. A comprehensive search identified two randomized controlled trials including 13,034 patients.

Sacubitril/valsartan was associated with a smaller decline in hemoglobin compared with ACE inhibitors or ARBs (MD −2.00; 95% CI −2.20 to −1.80; p<0.00001). Additionally, it significantly reduced the risk of new-onset anemia (RR 0.75; 95% CI 0.67–0.83; p<0.00001).

These findings suggest that sacubitril/valsartan may provide a hematologic benefit in heart failure by reducing hemoglobin decline and lowering anemia risk, although the limited number of trials warrants cautious interpretation.

Beta-Blocker Therapy in Heart Failure with Preserved Ejection Fraction - An Updated Systematic Review and Meta-Analysis

Presenter: Milena Dal Witt de Souza

Beta-blockers remain widely used in heart failure, although their role in heart failure with preserved ejection fraction (HFpEF) is uncertain. This meta-analysis evaluated the impact of beta-blockers on clinical outcomes in HFpEF using data from PubMed, Embase, and Cochrane databases. A total of 13 studies including 442,811 patients (48.3% women; mean age 76.04±8.38 years) were analyzed using a random-effects model.

Beta-blocker therapy was associated with a significant reduction in all-cause mortality (HR 0.81; 95% CI 0.73–0.90; p<0.001). Significant reductions were also observed in cardiovascular death (HR 0.76; 95% CI 0.64–0.90; p<0.01), heart failure hospitalization (HR 0.88; 95% CI 0.78–1.0; p=0.05), and the composite outcome of death or heart failure hospitalization (HR 0.89; 95% CI 0.82–0.98; p=0.02).

These findings suggest that beta-blockers may provide clinical benefit in HFpEF, with reductions in mortality and hospitalization-related outcomes.

Comparative Effectiveness and Safety of Spironolactone Versus Eplerenone in Patients with HFrEF and Chronic Kidney Disease: A Real-World Propensity-Matched Analysis

Presenter: Abdulraheem Eniola Hassan

Mineralocorticoid receptor antagonists are a key component of therapy in heart failure with reduced ejection fraction (HFrEF), but the optimal choice in patients with coexisting chronic kidney disease (CKD) is uncertain. This retrospective cohort study included adults with HFrEF and stage 3–5 CKD or ESRD between 2014 and 2023. After 1:1 propensity score matching, 1,182 patients were included in each group receiving spironolactone or eplerenone, with outcomes assessed over 12 months.

Spironolactone was associated with a higher risk of hyperkalemia compared to eplerenone (12.7% vs 8.6%; RR 1.48; p=0.004) and greater progression to end-stage heart failure (8.1% vs 5.2%; RR 1.54; p=0.013). All-cause hospitalizations were also modestly higher with spironolactone (46.0% vs 41.8%; HR 1.13; p=0.045). There were no significant differences between groups in all-cause mortality (17.9% vs 16.3%; HR 1.11; p=0.29), major adverse cardiovascular events, acute kidney injury, or ventricular arrhythmias.

These findings suggest that in patients with HFrEF & CKD, eplerenone was associated with lower risks of hyperkalemia, advanced heart failure progression & hospitalization, with similar mortality and cardiovascular outcomes compared to spironolactone.

Beta-Blockers in Heart Failure Populations with an Ejection Fraction of 40 Percent or Higher: Hidden Benefit or False Promise?

Presenter: Karim Ali

The role of beta-blockers in heart failure with preserved or mildly reduced ejection fraction (EF >40%) remains uncertain. This retrospective analysis included 20,852 adults with new-onset heart failure and EF >40%. Patients initiated on beta-blockers within one week of diagnosis were 1:1 propensity score matched to those not receiving beta-blockers, resulting in 4,633 matched pairs. The primary outcome was 1-year all-cause mortality, with multiple secondary clinical outcomes assessed.

Beta-blocker initiation was not associated with a difference in all-cause mortality (HR 1.06; 95% CI 0.91–1.25; p=0.46). However, it was associated with higher risks of heart failure exacerbation (HR 1.54; 95% CI 1.36–1.74; p<0.001), all-cause hospitalization (HR 1.12; 95% CI 1.03–1.21; p=0.005), ventricular arrhythmias (HR 1.34; 95% CI 1.09–1.65; p=0.006), and drug-related adverse events (HR 1.18; 95% CI 1.08–1.28; p<0.001). There were no significant differences in progression to reduced EF (HR 1.23; p=0.13) or natriuretic peptide elevation (HR 1.02; p=0.87).

These findings suggest that beta-blocker initiation in patients with heart failure and EF >40% does not improve mortality and may be associated with increased risks of adverse clinical outcomes.

Impact of Recombinant Human Brain Natriuretic Peptide (Rhbnp) Combined with Sacubitril/Valsartan on Cardiac Function and Inflammatory Markers in Acute Left Heart Failure: A Systematic Review and Meta-Analysis

Presenter: Maryam Ali

Acute left heart failure requires rapid optimization of hemodynamics and inflammation control. This meta-analysis evaluated the efficacy and safety of recombinant human BNP (rhBNP) combined with sacubitril/valsartan versus rhBNP alone. Four studies including 409 patients were analyzed using random-effects models, with outcomes reported as mean differences (MD) and odds ratios (OR).

Combination therapy significantly improved cardiac function, with higher left ventricular ejection fraction (MD 3.21%; 95% CI 1.37–5.04; p<0.001) and reduced left ventricular end-diastolic diameter (MD −5.03 mm; 95% CI −6.68 to −3.37; p<0.001). NT-proBNP levels were also lower (MD −1989.16 pg/mL; p<0.001). Inflammatory markers were reduced, including IL-6 (MD −2.29 pg/mL; p<0.001) and TNF-α (MD −1.46 pg/mL; p<0.001). There were no significant differences in cardiac troponin T (p=0.11) or hypotension risk (OR 1.13; p=0.76).

These findings suggest that rhBNP combined with sacubitril/valsartan improves cardiac function and reduces inflammation compared to rhBNP alone, with no increase in hypotension, although larger studies are needed.

Comparison of Beta Blocker Adherence Between Once vs Twice a Day Dosing Regimens in Patients Heart Failure with Reduced Ejection Fraction

Presenter: Sa Kong

Guideline-directed beta-blockers are a cornerstone of therapy in heart failure with reduced ejection fraction (HFrEF), but differences in dosing frequency may influence adherence. This retrospective cohort study included 2,699 adults hospitalized with HFrEF across 16 medical centers, excluding prior beta-blocker users and those with non-GDMT BB prescriptions at discharge. Patients were categorized into once-daily versus twice-daily regimens, and adherence was assessed using proportion of days covered (PDC ≥80%) at one year.

Among the cohort (mean age 66 years; 35% female), 72% were discharged on twice-daily beta-blockers (88% carvedilol, 9% bisoprolol, and 3% metoprolol succinate). There was no significant difference in achieving PDC ≥80% for the same dosing frequency between once- and twice-daily regimens (adjusted OR 1.10; 95% CI 0.92–1.31). However, once-daily regimens were associated with higher adherence compared to twice daily BB regimens irrespective of dosing frequency (aOR 1.32; 95% CI 1.08–1.60).

These findings suggest that dosing frequency alone may not significantly influence adherence to beta-blockers, although once-daily regimens may show modest advantages in overall adherence.

Readmission Outcomes in Patients with HFrEF: GDMT with Sacubitril/Valsartan Compared to the Maximum Daily Dose ACEi/ARB Only

Presenter: Hasnan M. Ijaz

Optimizing guideline-directed medical therapy in heart failure with reduced ejection fraction (HFrEF) may impact early outcomes, but real-world comparisons of sacubitril/valsartan versus ACEi/ARB remain limited. This retrospective cohort study included 2,733 encounters in adults with EF <40% and preserved renal function. Patients were categorized based on discharge therapy: sacubitril/valsartan (21%), ACEi/ARB (44%), or neither (34%), with adjusted analysis for 30-day readmission.

After adjustment, sacubitril/valsartan was not associated with reduced 30-day readmission compared to no therapy (OR 1.06; 95% CI 0.84–1.34; p=0.62). ACEi/ARB showed a non-significant trend toward lower readmission (OR 0.84; 95% CI 0.69–1.02; p=0.08). Heart failure-specific readmission and length of stay were numerically lower with ACEi/ARB and similar with sacubitril/valsartan.

These findings suggest that sacubitril/valsartan at discharge may not reduce early readmissions in unselected HFrEF patients, while ACEi/ARB may show a potential benefit that requires further validation.

ACC 2026, March 28 – 30, New Orleans, LA