Signed informed consent must be obtained prior to participation in the study
Patients ≥40 years of age, male or female
Currently hospitalized for or within 30 days following discharge of an acute decompensated HFpEF admission. Patients with a diagnosis of acute heart failure had to have symptoms and signs of fluid overload (i.e. jugular venous distention, edema or rales on auscultation or pulmonary congestion on chest x-ray). Eligible patients will be randomized no earlier than 36 hours and within 30 days post-discharge after presentation with acute HFpEF decompensation and meeting the following definitions of hemodynamic stability:
In-hospital randomized patients will have been hemodynamically stable defined in this study as:
SBP≥100mmHg for the preceding 6 hours prior to randomization; no symptomatic hypotension
No increase (intensification) in i.v. diuretic dose within last 6 hours prior to randomization
No i.v. inotropic drugs for 24 hours prior to randomization
No i.v. vasodilators including nitrates within last 6 hours prior to randomization
Out-of-hospital randomization patients will have been hemodynamically stabilized defined in this study as:
SBP ≥100mmHg; no symptomatic hypotension
No increase (intensification and/or change to IV) in diuretic dose within last 24 hours prior to randomization
No i.v. inotropic drugs for 24 hours prior to randomization
HFpEF with most recent LVEF >40% (within past 3 months)
Elevated NT-proBNP or BNP at the time of screening (and within 72 hours from inhospital screening to out-of-hospital randomization, if applicable)
Patients not in AF at the time of biomarker assessment: NT-proBNP ≥ 500pg/mL or BNP ≥ 150 pg/mL; patients in AF at the time of biomarker assessment: NT-proBNP ≥ 1000pg/mL or BNP ≥ 300 pg/mL
Patients recruited in-hospital will be randomized based on the qualifying local lab value in-hospital NT-proBNP or BNP value. In-hospital is the preferred method of enrollment.
Patients enrolled out-of-hospital can be randomized based on their NT-proBNP or BNP value in the following way:
if enrolling in out-of-hospital setting then need eligible screening/local NTproBNP/BNP within 72 hours of randomization. The test value could be from recent hospitalization if within 72 hours or would require (re)drawing NT-proBNP or BNP labs in out-of-hospital setting if the lab value is not already available within the last 72 hours
Has not taken an ACEi for 36 hours prior to randomization
Any clinical event within the 90 days prior to randomization that could have reduced the LVEF (i.e., MI, CABG), unless an echo measurement was performed after the event confirming the LVEF to be >40%
Currently taking Entresto™ (sacubitril/valsartan) or any prior use
eGFR < 20ml/min/1.73 m2 as measured by the simplified Modification of Diet in Renal Disease (MDRD) formula at most recent assessment prior to randomization and within 24 hours prior to inpatient randomization or 72 hours prior to outpatient randomization
Serum potassium > 5.2 mEq/L at most recent assessment prior to randomization and within 24 hours prior to inpatient randomization or 72 hours prior to outpatient randomization
Acute coronary syndrome, stroke, transient ischemic attack; cardiac, carotid or other major CV surgery; percutaneous coronary intervention (PCI) or carotid angioplasty, within 30 days prior to randomization
Probable alternative diagnoses that in the opinion of the investigator could account for the patient's HF symptoms (i.e. dyspnea, fatigue) such as significant pulmonary disease (including primary pulmonary HTN), anemia or obesity. Specifically, patients with the following are excluded:
Severe pulmonary disease including chronic obstructive pulmonary disease (COPD) (i.e. requiring home oxygen, oral steroid therapy) or
Hemoglobin (Hgb) < 9.5 g/dL males and < 9 g/dL females within 30 days prior to randomization or
Body mass index (BMI) > 50 kg/m2 at randomization
Isolated right HF in the absence of left-sided structural heart disease
History of hypersensitivity (i.e. including angioedema), known or suspected contraindications, or intolerance to any of the study drugs including ARNIs (i.e. sacubitril/valsartan), and/or ARBs
Patients with a known history of angioedema due to any etiology
Patients with a history of heart transplant or LVAD, currently on the transplant list, or with planned intent to implant LVAD or CRT device within the initial three months of enrollment during the trial
A cardiac or non-cardiac medical condition other than HF with an estimated life expectancy of < 12 months
Known pericardial constriction, genetic hypertrophic cardiomyopathy, or infiltrative cardiomyopathy including amyloid heart disease (amyloidosis)
Life-threatening or uncontrolled dysrhythmia, including symptomatic or sustained ventricular tachycardia and atrial fibrillation or flutter with a resting ventricular rate >110 bpm
Clinically significant congenital heart disease felt to be the cause of the patient's symptoms and signs of HF
Coronary or carotid artery disease or valvular heart disease likely to require surgical or percutaneous intervention within the duration of the trial
Any surgical or medical condition, which in the opinion of the investigator, may place the patient at higher risk from his/her participation in the study, or is likely to prevent the patient from complying with the requirements of the study or completing the study
Known hepatic impairment (as evidenced by total bilirubin > 3 mg/dL, or increased ammonia levels, if performed), or history of cirrhosis with evidence of portal hypertension such as varices
Participation in any other clinical trial involving investigational agents or devices within the past 30 days
Current confirmed COVID19 infection
Past COVID19 infection with persistent symptom burden suspected due to COVID19 Persistent symptoms may include, but are not limited to, continued cough, breathing difficulty, muscle/joint aches, and gastrointestinal symptoms from the time of COVID19 infection onward.
Pregnant or nursing (lactating) women, where pregnancy is defined as the state of a female after conception and until the termination of gestation, confirmed by a positive hCG laboratory test.
Women of childbearing potential, defined as all women physiologically capable of becoming pregnant, unless they are using basic methods of contraception during dosing of study treatment. Basic contraception methods include:
Total abstinence (when this is in line with the preferred and usual lifestyle of the patient. Periodic abstinence (e.g. calendar, ovulation, symptothermal, post-ovulation methods) and withdrawal are not acceptable methods of contraception.
Female sterilization (have had surgical bilateral oophorectomy with or without hysterectomy), total hysterectomy, or tubal ligation at least six weeks before taking investigational drug. In case of oophorectomy alone, only when the reproductive status of the woman has been confirmed by follow up hormone level assessment.
Male sterilization (at least 6 months prior to screening). For female patients on the study, the vasectomized male partner should be the sole partner for that patient.
Barrier methods of contraception: Condom or Occlusive cap (diaphragm or cervical/vault caps).
Use of oral (estrogen and progesterone), injected, or implanted hormonal methods of contraception or other forms of hormonal contraception that have comparable efficacy (failure rate <1%), for example, hormone vaginal ring or transdermal hormone contraception or placement of an intrauterine device (IUD) or intrauterine system (IUS).