ACEi to ARNI Washout — EECC MCQ

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EasyHeart FailureACEi to ARNI WashoutEECC

A 65-year-old man with HFrEF (LVEF 30%) on ramipril 10 mg develops persistent cough. The plan is to switch to sacubitril/valsartan. What washout period is required?

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Correct answer: B — A minimum 36-hour ACE-inhibitor washout

Sacubitril/valsartan must NOT be co-administered with an ACE inhibitor due to the risk of angioedema. Both neprilysin (inhibited by sacubitril) and ACE degrade bradykinin; dual inhibition causes excessive bradykinin accumulation, dramatically increasing angioedema risk. A minimum 36-hour washout from the last ACEi dose is mandatory before starting sacubitril/valsartan (Class III contraindication for concurrent use). ARBs do not affect bradykinin metabolism, so switching from ARB to sacubitril/valsartan does NOT require a washout period. The starting dose of sacubitril/valsartan depends on the previous ACEi/ARB dose and blood pressure: 24/26 mg bd for ACEi-naïve or low-dose, 49/51 mg bd if previously on target-dose ACEi/ARB.

Reference: ESC (2023): HF Guidelines; BNF: https://bnf.nice.org.uk/