The Effect of Sacubitril-Valsartan on Ventricular Arrhythmia Burden in Patients With Heart Failure With Reduced Ejection Fraction

Abstract

Background. The available literature does not definitively clarify the impact of sacubitril / valsartan therapy on the ventricular and supraventricular arrhythmic burden in HFrEF patients. The primary aim of our study was to evaluate, in a population of HFrEF patients already underwent to ICD implantation in primary prevention, the additive value of sacubitril / valsartan versus standard medical therapy on ventricular and supra-ventricular arrhythmic burden and on cardiac mechanics investigated through echocardiographic global longitudinal strain analysis. Methods. 32 patients were enrolled according to ESC recommendations. The initial assessment, once confirmed at the screening the presence of all the necessary conditions for enrollment, included: cardiological examination, EKG, laboratory tests, echocardiogram with global longitudinal strain calculation and ICD check. At 6 and 12 months ICD check and echocardiogram with strain analysis were performed. Results. We observed, after one year follow up, a significant reduction of the arrhythmic burden, as premature ventricular contractions (PVC/h p=0,0116) and non-sustained ventricular tachycardia (NSVT, 56,2% of patients had NSVT at the enrollment and 37,5% after one year, relative risk reduction RRR=33,4%, p=0,0118We registered also a sustained ventricular arrhythmias reduction, as the significant reduction of appropriate defibrillator interventions demonstrated (9,4% vs 3,1%, RRR=67%). Echocardiographic evaluations showed an improvement of left ventricular mechanical performance, witnessed by global longitudinal strain (GLS), that was linearly related to the reduction of ventricular arrhythmic activity according to a direct proportionality. The link between mechanical stress and arrhythmic burden is highlighted in our data by the direct correlation between the improvement of GLS (-8,22 VS -9,92, p=0,0004) and the reduction of the PVC/h (p=0,0027), to support the assumption that sacubitril/valsartan reduces the arrhythmic burden by reducing myocardial parietal stress levels and acting on reverse remodeling. Conclusion. In our study, in a population of patients with HFrEF and ICD/CRT-D carriers, sacubitril/valsartan reduced both the ventricular arrhythmic burden and the appropriate ICD-shocks. The benefit was early and global with a positive impact both on cardiac performance (in terms of systolic function and chambers volumes) and reverse cardiac remodeling.