CAT

1. A N G I O T E N S I N - N E P R I L Y S I N I N H I B I T O R
C A R L A N G E L O O N G A M A N T E , M D
F I R S T Y E A R
I N T E R N A L M E D I C I N E R E S I D E N T
CAT on Therapy

2.  Presented a case of 27 year/old male
 Presented with bipedal edema, known Cardiomegaly
 2D Echo: EF 30-35%, Global Wall Hypokinesia,
Moderately Depressed Systolic Function.

3.  Clinical Question:
 Will an Angiotensin-Neprilysin Inhibitor decrease the
incidence of re-admission for heart failure, and or improve
patient’s outcome?

4. Clinical Question:
 For patients hospitalized with Acute Decompensated
Heart Failure; will the initiation of treatment with
an Angiotensin-Neprilysin Inhibitor be safe and
effective?
Citation: Velasquez, E.J, et al. Angiotensin-Neprilysin
Inhibition in Acute Decompensated Heart Failure

5. A. Apprasing Directness
Clinical Question Journal
Patient Hospitalized patients
with Acuted
Decompensted Heart
Failure
Heart failure with
reduced ejection
fraction, hospitalized
for acute
decompensated heart
failure
Intervention Angiotensin-Neprilysin
inhibitor
Angiotensin –
Neprilysin inhibitor
Outcome Effective for patients on
Angiotensin-Neprilysin
Inhibitor
Effective for patients on
Angiotensin-Neprilysin
Inhibitor
Methodology Multicenter
Randomized, Double
Blind, Active Controlled

6. B. Appraising Validity
Were patients randomly assigned to treatment groups?
Yes as stated in the study design- It was
conducted in a multicenter, randomized, double-blind,
active-controlled trial of the in-hospital initiation of
sacubitril-valsartan therapy as compared to enalapril
therapy.
Was allocation concealed?
No. as stated in the study design, it had an open-
label treatment with sacubitril/valsartan for the
remaining 4 weeks of the study.

7. B. Appraising Validity
Were baseline characteristics similar at the start of the
trial?
Yes as shown in table 1
Were patients blinded to treatment assignment?
Yes, as stated in the study design
Were Caregivers blinded to treatment assignment?
Blinding of caregivers was not mentioned.
Were outcome assessors blinded to treatment
assignment?
blinding of the Assessors for the study were not
mentioned.

8. B. Appraising Validity
Were all patients analyzed in the groups to which they
were originally randomized?
No, there were 91 patients in the treatment
group that had prematurely dropped-out while 96
patients was noted on the controlled group
Was follow-up rate adequate?
Yes, there were only 5 drop outs from the
treatment group and 7 drop outs from the control
group.

9. C. Appraising the Results
How large was the effect of treatment?
Risk in Control: 61/441 = 13.8%
Risk in Treatment: 35/440 = 8%
RRR= 13.8-8/ 13.8= 42.26%
Since RRR is >0%, treatment is beneficial
ARR= 13.8-8.0 = 6%
Since ARR is >0%, treatment is beneficial
RR= 8/13.6 = 58%
Since RR is <1, treatment is beneficial
NNT= 100/6 = 16.67
How precise was the estimate of treatment effect?
RR 0.94 with 93% CI 0.78-1.10, since both ends of the
confidence interval is <1.0. treatment is surely beneficial than control

10. D. Assessing Applicability
Biologic Issues
Sex, Age and Race doesn’t affect the applicability
of this study.
Socioeconomic Issues
Not readily available for government
institutions.

11. E. Individualizing the Results
Baseline Risk 20%
RR= 1-RRR = 1-0.42 =0.58
Rt = Rc x RR =20% x 0.58=11.6%
ARR = 20% -11.6% = 8.4%
NNT = 100/8,4 = 11
The risk of composite clinical events falls from
20% to 11.6% with the use of Angiotensin-Neprilysin
inhibitor. Number needed to treat (NNT) was 11

12. F. Conclusion
Journal Author’s : Initiation of Angiotensin-
Neprylisin Inhibitor for acute decompensated heart
failure showed consistent benefit as compared to ACE
inhibitors in the sub group analysis .
Reviewers : ANRI is effective in treating acute
decompensated heart failure to improve composite
clinical events. However, the cost may outweigh the
benefits of the treatment since it is nor readily
available and an independent study is further required
to validate its effectiveness.

13. Thank you..