In heart failure with reduced ejection fraction, which statement about ARNI use is correct?

• A. ARNI can be used in eligible patients
• B. ARNI replaces beta-blockers as first-line therapy
• C. ARNI is contraindicated in patients with kidney disease
• D. ARNI has no mortality benefit

Answer: (A)

Using an ARNI (sacubitril/valsartan) in heart failure with reduced ejection fraction is beneficial because it combines neprilysin inhibition with angiotensin receptor blockade, reducing both vascular resistance and harmful neurohormonal activation. This dual action lowers mortality and heart failure hospitalizations in eligible patients, a benefit demonstrated in major trials and reflected in guideline recommendations to replace an ACE inhibitor or an ARB with an ARNI in chronic symptomatic HFrEF.

It's appropriate to consider ARNI in patients already on ACE inhibitors or ARBs who meet eligibility, after ensuring stability and following a proper switch protocol (including a washout period if transitioning from an ACE inhibitor). ARNI is not meant to replace beta-blockers as first-line therapy—beta-blockers remain foundational and are often continued alongside ARNI. It is not an absolute contraindication in kidney disease, but kidney function and electrolytes must be monitored, and there are specific cautions (such as prior angioedema with ACE inhibitors, and risks of hypotension and hyperkalemia). Finally, ARNI has a proven mortality benefit, so denying its use in eligible patients would miss a key advance in therapy.