A 62-year-old man with NYHA class II heart failure with reduced ejection fraction (LVEF 28%) on lisinopril 20 mg daily, metoprolol succinate, and furosemide is being switched to sacubitril-valsartan. His BP is 118/72 mmHg, potassium 4.3 mEq/L, and eGFR 58 mL/min/1.73m². Which statement about this switch is correct according to the PARADIGM-HF trial evidence?
- A Lisinopril can be stopped and sacubitril-valsartan started the next morning.
- B Sacubitril-valsartan is initiated at full target dose immediately to achieve rapid mortality benefit.
- C Lisinopril must be stopped and a 36-hour washout observed before starting sacubitril-valsartan to reduce angioedema risk. ✓
- D Sacubitril-valsartan reduced all-cause mortality but not heart failure hospitalizations compared with enalapril.
Correct answer: C. Lisinopril must be stopped and a 36-hour washout observed before starting sacubitril-valsartan to reduce angioedema risk.
Explanation
PARADIGM-HF demonstrated sacubitril-valsartan was superior to enalapril in reducing both cardiovascular death and heart failure hospitalizations (NNT 21). The trial required a 36-hour washout after ACE inhibitor cessation before starting sacubitril-valsartan to minimize angioedema risk. Starting at full dose or without washout increases angioedema risk. Option D is wrong because the trial reduced both endpoints.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.