Ventricular arrhythmias and ARNI: is it time to reappraise their management in the light of new evidence?

Abstract

The remarkable scientific progress in the treatment of patients with heart failure (HF) and reduced ejection fraction (HFrEF) has more than halved the risk of sudden cardiac death (SCD) in this setting. However, SCD remains one of the major causes of death in this patient population. Beyond the acknowledged role of beta blockers and inhibitors of the renin-angiotensin-aldosterone system (RAAS), a new class of drugs, the angiotensin receptor neprilysin inhibitors (ARNI), proved to reduce the overall cardiovascular mortality and, more specifically, the risk of SCD in HFrEF patients. The mechanism by which ARNI may reduce the mortality connected with harmful ventricular arrhythmias is not utterly clear. A variety of direct and indirect mechanisms have been suggested, but a favorable left ventricular reverse remodeling seems to play a key role in this setting. Furthermore, the well-known protective effect of implantable cardioverter-defibrillator (ICD) has been debated in HFrEF patients with non-ischemic cardiomyopathy (NICM) arguing against the role of primary prevention ICD in this setting, particularly when ARNI therapy is considered. The purpose of this review was to provide insights into the SCD mechanisms involved in HFrEF patients together with the current role of electrical therapies and new drug agents in this setting.

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All authors read and approved the final manuscript.

• Study conception and design: Drs. Andrea Lorenzo Vecchi, Jacopo Marazzato

• Literature search and data analysis: Drs. Andrea Lorenzo Vecchi, Raffaele Abete, Jacopo Marazzato

• Drafting of manuscript: Drs. Andrea Lorenzo Vecchi, Raffaele Abete, Jacopo Marazzato, Attilio Iacovoni

• Critical revision: Prof. Roberto De Ponti, Prof. Andrea Mortara, Prof. Michele Senni

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Correspondence to Andrea Lorenzo Vecchi.

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Drs. Andrea Lorenzo Vecchi, Raffaele Abete, Jacopo Marazzato, Attilio Iacovoni, and Roberto De Ponti declare that they have no conflicts of interest or financial ties to disclose.

Dr. Michele Senni declares financial interest for consultancy with Novartis, Merck, Bayer, Vifor Pharma, Abbott, Boehringer Ingelheim, AstraZeneca, Bioventrix, and Servier.

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Vecchi, A.L., Abete, R., Marazzato, J. et al. Ventricular arrhythmias and ARNI: is it time to reappraise their management in the light of new evidence?. Heart Fail Rev (2020). https://doi.org/10.1007/s10741-020-09991-3

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Keywords

  • Heart failure reduced ejection fraction
  • Sudden cardiac death
  • Angiotensin receptor neprilysin inhibitors
  • Sacubitril/valsartan
  • Ventricular arrhythmias
  • Implantable cardioverter-defibrillator