Valsartan Alone is as Good as Valsartan Sacubitril (Entresto) in Advanced Heart Failure
Entresto is a relatively new medication for congestive heart failure. It is a combination of valsartan and sacubitril. A recent study showed valsartan alone is as good as valsartan sacubitril in advanced heart failure. These results are not surprising. They are consistent with studies that show chronic excessive production of the hormones angiotensin II (blocked precisely by losartan or valsartan) and aldosterone (blocked precisely by spironolactone) in heart failure blunts the effect of sacubitril.
These facts point to a problem in the research that led to the original approval of Entresto. It compared Entresto with enalapril which has a similar beneficial effect on heart failure as valsartan. At the time, optimal medical treatment for heart failure included medications from three categories like enalapril, metoprolol, and spironolactone. The guidelines recognized the critical importance of blocking the effects of angiotensin II and aldosterone which drive the biology that causes the disease. Compared with enalapril, Entresto lowered the risk of dying or hospitalization by about 20%, but only half the patients in the trial were on a medication to block aldosterone effects. Had they been on optimal medical treatment, Entresto effects would very likely have been blunted there as well. All new treatments should be tested against a background of optimal medical treatment.
In value-based medicine, cost is an important consideration. Valsartan is $20 a month. Losartan is $10 a month. Entresto is over $600 a month. That is 30 times the cost of valsartan. It is 60 times the cost of losartan. There are three million people in this country with heart failure. Most of them are on Medicare. Failure to provide value-based optimal medical treatment for these patients is costing every one of us and contributes to the financial threat to Medicare solvency. If you are part of a Medicare Advantage program, these facts are important to your success. Seven percent of Medicare patients have congestive heart failure. Every patient with this type of heart failure should receive a beta blocker like carvedilol, lisinopril or losartan/valsartan, and a medication from the same class as spironolactone. That would improve quality of life, function, reduce cost, and lower the number of deaths and hospitalizations. This is the reason optimal medical treatment is so critical. It is why we need primary care teams focused on chronic cardiovascular disease and related conditions. Carefully designed protocols designed to provide maximal benefit at the lowest cost are critical to success.