Drawing Boundaries around PARADISE

This editorial discusses the role of sacubitril-valsartan (an angiotensin receptor–neprilysin inhibitor, ARNI) in heart failure treatment, particularly after acute myocardial infarction (MI). While the PARADIGM-HF trial demonstrated ARNI's superiority over ACE inhibitors in chronic heart failure with reduced ejection fraction, the PARADISE-MI trial did not show significant benefits of sacubitril-valsartan over ramipril (an ACE inhibitor) in post-MI patients. The authors highlight the challenges of neurohormonal inhibition, including higher rates of hypotension with ARNI, and emphasize that ACE inhibitors or ARBs remain the guideline-recommended treatment post-MI. They suggest reserving ARNI for stable outpatients with persistent low ejection fraction, where the benefit-risk ratio may be more favorable.

This editorial discusses the role of sacubitril-valsartan (an angiotensin receptor–neprilysin inhibitor, ARNI) in heart failure treatment, particularly after acute myocardial infarction (MI). While the PARADIGM-HF trial demonstrated ARNI's superiority over ACE inhibitors in chronic heart failure with reduced ejection fraction, the PARADISE-MI trial did not show significant benefits of sacubitril-valsartan over ramipril (an ACE inhibitor) in post-MI patients. The authors highlight the challenges of neurohormonal inhibition, including higher rates of hypotension with ARNI, and emphasize that ACE inhibitors or ARBs remain the guideline-recommended treatment post-MI. They suggest reserving ARNI for stable outpatients with persistent low ejection fraction, where the benefit-risk ratio may be more favorable.