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Association of angiotensin receptor-neprilysin inhibitor duration with latent remodeling following implantable
Jooyeon Lee1, Jaewon Oh1, Daehoon Kim1
1Department of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
Insights
Shorter exposure to angiotensin receptor neprilysin inhibitors (ARNI) before implantable cardioverter defibrillator (ICD) implantation is linked to latent left ventricular reverse remodeling (LVRR) in nonischemic dilated cardiomyopathy. Sufficient guideline-directed medical therapy is crucial for optimizing LVRR.
Area of Science:
- Cardiology
- Heart Failure Management
- Device Therapy
Background:
- The optimal duration of angiotensin receptor neprilysin inhibitors (ARNI) therapy before implantable cardioverter defibrillator (ICD) implantation is unknown.
- Reverse remodeling may continue post-ICD implantation in nonischemic dilated cardiomyopathy (NIDCM).
- Predictors of latent left ventricular reverse remodeling (LVRR) after ICD implantation are unclear.
Purpose of the Study:
- To investigate the association between pre-ICD ARNI therapy duration and latent LVRR in NIDCM patients.
- To identify predictors of latent LVRR in this population.
Main Methods:
- Retrospective analysis of 75 NIDCM patients with LVEF ≤35% receiving ARNI before primary prevention ICD.
- Latent LVRR defined as ≥10% LVEF increase to ≥40% at 1-year post-implant.
- Multivariable logistic regression used to identify LVRR predictors.
Main Results:
- 29.3% of patients achieved latent LVRR at 1 year.
- Shorter time from HF diagnosis and ARNI initiation to ICD implant were associated with latent LVRR.
- Cardiac MRI showed no differences in fibrosis markers; conventional variables were not predictive.
Conclusions:
- Shorter ARNI exposure before ICD implantation independently predicts latent LVRR in NIDCM.
- Sufficient guideline-directed medical therapy (GDMT) is needed to optimize reverse remodeling.
- Continued ICD protection is necessary due to residual arrhythmic risk.
Background:
The optimal duration of angiotensin receptor-neprilysin inhibitor (ARNI) exposure before implantable cardioverter-defibrillator (ICD) implantation remains undefined. In nonischemic dilated cardiomyopathy (NIDCM), reverse remodeling may continue beyond device implantation. However, predictors of post-implant latent left ventricular reverse remodeling (LVRR) remain unclear.
Objective:
This study investigated the association between duration of pre-ICD ARNI therapy and latent LVRR in patients with NIDCM.
Methods:
Seventy-five patients with NIDCM (69.3% male, mean age 61 years) with LVEF of ≤35% and prior ARNI treatment before primary prevention ICD implantation were retrospectively analyzed. Latent LVRR was defined as an absolute ≥10% increase in LVEF with a final LVEF of ≥40% at 1-year post-implant. Multivariable logistic regression identified the predictors of latent LVRR.
Results:
At 1 year, 22 patients (29.3%) exhibited latent LVRR. Shorter duration from heart failure diagnosis (4.8 vs 30.1 months; odds ratio, 0.88, P = .007) and ARNI initiation (2.3 vs 7.2 months; odds ratio, 0.90, P = .029) to ICD implant were independently associated with latent LVRR. Cardiac magnetic resonance imaging analysis showed uniformly elevated fibrosis markers across groups, with no difference observed in native T1, T2, extracellular volume, or late gadolinium enhancement. Conventional variables, including age, sex, QRS duration, heart rate, and late gadolinium enhancement burden, were not predictive. Over a median follow-up of 33.8 months, ventricular arrhythmia incidence was comparable (9.1% vs 7.5%).
Conclusion:
Shorter ARNI exposure before ICD implantation was independently associated with latent LVRR, highlighting the need for sufficient guideline-directed medical therapy to optimize reverse remodeling, whereas residual arrhythmic risk warrants continued ICD protection.
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