Commentary to Impact of Sacubitril-Valsartan Treatment on Diastolic Function in Patients with Heart Failure and Reduced Ejection Fraction

The field of usefulness of the angiotensin receptor–neprilysin inhibitor (ARNI) sacubitril-valsartan in patients with heart failure (HF) with preserved ejection fraction (HFpEF), as well as the impact of ARNI on diastolic function, are still uncharted. In contrast with the strong impact of ARNI on the prognosis of HF with reduced ejection fraction (HFrEF) [1], due to an improvement in systolic function, ARNI failed to reduce total hospitalization rate and cardiovascular death in patients with HFpEF [2]. A sub-analysis from Prospective Comparison of ARNI with Angiotensin Converting Enzyme Inhibitors (ACE-I) to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial showed that circulating levels of Brain Natriuretic Peptide (BNP) increased meaningfully, early after initiation of sacubitril/ valsartan, while N-terminal pro-hormone BNP (NTproBNP) level resulted less directly influenced than BNP by Neprilysin inhibition. However, on-treatment concentration of both biomarkers independently predicted the risk of major adverse cardiovascular outcomes. This finding suggested to change the traditional point of view on natriuretic peptides (NPs) application to monitor bio-humoral response to the therapy of HFrEF with ARNI.