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Angiotensin-Converting Enzyme Inhibitor Washout Period Prior to Angiotensin Receptor/Neprilysin Inhibitor Initiation
Kaanan Shah1, Stella Mabhugu1, Jessica Obioma1,2
1College of Pharmacy, The University of North Texas Health Science Center, Fort Worth, TX, USA.
Insights
Most patients (67%) switching from ACE inhibitors to ARNIs did not receive the recommended 36-hour washout, but this did not increase adverse events or heart failure readmissions.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Pharmacy
Background:
- The 2022 AHA-ACC HFSA Guideline recommends Angiotensin Receptor/Neprilysin Inhibitors (ARNIs) for heart failure with reduced ejection fraction (HFrEF).
- A 36-hour washout period is advised when switching from Angiotensin-Converting Enzyme Inhibitors (ACEi) to ARNIs to mitigate adverse effects like angioedema.
- This study examines adherence to this washout protocol in a real-world clinical setting.
Purpose of the Study:
- To determine the rate of adherence to the 36-hour washout period when transitioning patients from ACEi to ARNI.
- To evaluate secondary outcomes including 90-day heart failure exacerbation readmissions and adverse events (angioedema, hypotension, AKI, hyperkalemia).
Main Methods:
- Retrospective cohort study of HFrEF patients transitioned from ACEi to ARNI between March 2016 and December 2022.
- Exclusion criteria included lack of ACEi or ARNI use during admission or ejection fraction >40%.
- Pearson chi-square analysis was used for categorical data.
Main Results:
- Of 33 patients, only 67% received the full 36-hour washout period.
- No significant differences were observed in hospital readmission rates or adverse events between groups.
- No patients experienced hyperkalemia or angioedema.
Conclusions:
- This study highlights potential deviations from recommended washout protocols when switching from ACEi to ARNI in HFrEF patients.
- The observed adherence rate suggests a need for further investigation into prescribing practices.
- Larger, multicenter studies are warranted to validate these findings and explore the pharmacist's role in protocol adherence.
Background:
The 2022 AHA-ACC HFSA Guideline for Management of Heart Failure recommend initiating an angiotensin receptor/neprilysin inhibitor (ARNI) in patients with heart failure with reduced ejection fraction (HFrEF) who can tolerate an angiotensin-converting enzyme inhibitor (ACEi). The manufacturer recommends initiating a 36-hour washout period when switching from ACEi to ARNI due to an increased risk of adverse effects, including angioedema. This study investigated the adherence to the washout period when transitioning from ACEi to ARNI at a community hospital.
Objectives:
The primary objective was to assess the rate of adherence to the 36-hour washout when transitioning patients from ACEi to ARNI. Secondary outcomes included heart failure exacerbation readmission rates within 90 days and the rate of adverse effects (angioedema, hypotension, acute kidney injury, and hyperkalemia).
Methods:
This was a retrospective cohort study including patients with HFrEF who were transitioned from ACEi to ARNI during their hospital stay between March 1, 2016 and December 31, 2022. Patients were excluded if they did not receive an ACEi or ARNI during their admission or if they had an ejection fraction >40%. Pearson chi-square was used to analyze categorical data.
Results:
Of 33 patients included in this study, 67% received the full 36-hour washout period when transitioning from ACEi to ARNI. There were no significant differences between the rates of hospital readmissions or adverse effects between the groups. No patients experienced hyperkalemia or angioedema.
Conclusion And Relevance:
This is the first study to our knowledge to describe real-world prescribing practices when transitioning patients from ACEi to ARNI for the treatment of HFrEF. Larger, multicenter studies are needed to provide more data on prescribing practices outside this single center. Future research should also include pharmacist's role in adhering to the recommended washout.
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