ARNI Dose Reduction for Hypotension — EECC MCQ

Correct answer: D — Reduce sacubitril/valsartan dose to 49/51 mg bd rather than stopping — maintaining some ARNI therapy at a reduced dose provides ongoing mortality benefit; complete withdrawal should be avoided; also address other BP-lowering contributors (reduce diuretics if euvolaemic, timing adjustments)

Symptomatic hypotension on ARNI is common (SBP <90 occurs in ~5-15%) and requires careful management: (1) FIRST: reduce non-essential BP-lowering agents — diuretics (if euvolaemic), non-cardiac antihypertensives, nitrates; (2) Timing: take ARNI with food, split doses to different times, take at bedtime; (3) If still hypotensive: REDUCE ARNI dose (97/103 → 49/51 → 24/26 mg bd) rather than stopping — any dose provides some neurohormonal modulation and mortality benefit; (4) Do NOT abruptly switch to full-dose ACEi (this causes rebound neurohormonal activation). The 2023 ESC HF Guidelines emphasise maintaining ALL four GDMT pillars at the highest tolerated doses. If SBP is persistently <90 mmHg despite all adjustments, the lowest available ARNI dose (24/26 mg bd) may be continued with close monitoring. Complete cessation is a last resort.

Reference: ESC (2023): HF Guidelines