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hospitalization for acute heart failure constitutes an opportunity to initiate and successfully up-titrate guideline-recommended therapies&#46; The international guidelines support the initiation and up-titration of all disease-modifying therapy &#40;DMT&#41; early after hemodynamic stabilization following an acute heart failure event in order to improve prognosis&#44; particularly during the vulnerable phase early after discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Although this has been demonstrated for previous classes of heart failure DMT&#44; there was still a gap in evidence on the optimal time for the initiation of sacubitril&#47;valsartan in HFrEF patients after an acute decompensation&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The TRANSITION and PIONEER-HF trials evaluated the initiation of sacubitril&#47;valsartan in severe HFrEF patients after stabilization following an acute heart failure episode&#44; both before and early after discharge&#44; with no run-in phase&#44; closer to the challenges of everyday clinical practice&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The TRANSITION study assessed the safety and tolerability of sacubitril&#47;valsartan in patients admitted with HFrEF&#44; after stabilization following an acute heart failure episode&#46; Patients were enrolled to initiate sacubitril&#47;valsartan either in the hospital or shortly after discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> At 10 weeks&#44; when more than 86&#37; of patients had been receiving sacubitril&#47;valsartan for two weeks or longer without interruption&#44; about half the patients in the study had achieved the primary endpoint&#44; which was a target dose of 200 mg of sacubitril&#47;valsartan twice daily within 10 weeks in both groups&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> The incidence of adverse events and discontinuation of sacubitril&#47;valsartan due to adverse events was also similar in both in-hospital and outpatient settings&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The tolerability of sacubitril&#47;valsartan in TRANSITION appears to be comparable to that reported for beta-blockers and ACEIs&#47;ARBs under real-life conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">PIONEER-HF was designed to assess the safety&#44; tolerability and efficacy of in-hospital initiation of sacubitril&#47;valsartan compared to enalapril in stabilized HFrEF patients who had been admitted for acute decompensation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The primary endpoint was the time-averaged proportional change in NT-proBNP from baseline through weeks 4 and 8&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;8</span></a> Patients treated with sacubitril&#47;valsartan achieved a 47&#37; reduction from baseline in time-averaged NT-proBNP&#44; compared to a 25&#37; reduction with enalapril&#44; translating into a statistically significant 29&#37; greater reduction with sacubitril&#47;valsartan over the ACEI &#40;95&#37; CI&#58; 0&#46;63-0&#46;81&#59; p&#60;0&#46;0001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Significant reductions in NT-proBNP were observed in sacubitril&#47;valsartan patients as early as one week after treatment initiation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> There were no new safety signals identified&#44; and the safety profile was comparable to that observed in PARADIGM-HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;4</span></a> Rates of serious adverse events occurring with a frequency of &#8805;0&#46;5&#37; were similar between the sacubitril&#47;valsartan and enalapril groups&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In a pre-specified exploratory analysis&#44; the composite endpoint of death&#44; rehospitalization for HF&#44; left ventricular assist device implantation or listing for cardiac transplant occurred in 41 &#40;9&#46;3&#37;&#41; patients in the sacubitril&#47;valsartan group and in 74 &#40;16&#46;8&#37;&#41; in the enalapril group &#40;HR 0&#46;54&#44; 95&#37; CI 0&#46;37-0&#46;79&#59; p&#61;0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The benefit was driven by reductions in death and rehospitalization among patients treated with sacubitril&#47;valsartan&#46; The number needed to treat to prevent one such clinical event during eight weeks of follow-up was 13&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Moreover&#44; TRANSITION and PIONEER-HF are the first randomized studies to provide data on the use of sacubitril&#47;valsartan in new-onset and ACEI&#47;ARB-naive HFrEF patients&#46; In fact&#44; approximately 34&#37; of patients in PIONEER and 29&#37; in TRANSITION were newly diagnosed&#44; with no prior history of heart failure&#44; and slightly more than 50&#37; of patients in PIONEER and 24&#37; in TRANSITION were not receiving ACEI&#47;ARB therapy at the time of admission&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> Recently presented data from PIONEER-HF also showed that sacubitril&#47;valsartan&#44; titrated to target dose based on systolic blood pressure during hospitalization&#44; had the same beneficial effect on the primary and safety endpoints in ACEI&#47;ARB-naive patients&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary&#44; the TRANSITION and PIONEER-HF results provide complementary data to PARADIGM-HF&#44; addressing previous gaps in evidence&#46; They support the use of sacubitril&#47;valsartan both during hospital stay and in outpatient settings&#46; Although there are still a few unanswered questions and unpublished results from both trials&#44; the data from PIONEER-HF and TRANSITION support the in-hospital initiation of sacubitril&#47;valsartan in all NYHA II-III patients early after stabilization&#44; and independently of prior HF diagnosis or ACEI&#47;ARB exposure&#46; There are now grounds for initiating therapy in HFrEF with ACEI safely as a first option&#44; in both in-hospital and outpatient settings&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">On the basis of this new information&#44; our paper &#8220;Sacubitril&#47;valsartan&#58; a practical guide&#8221; should be revisited as in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">C&#226;ndida Fonseca has received fees from Amgen&#44; AstraZeneca&#44; Bayer&#44; Boehringer-Ingelheim&#44; Novartis&#44; Orion&#44; Roche&#44; Servier and Vifor &#40;companies that develop and market tests and&#47;or treatments in the area of HF&#41; for HF consulting&#44; sitting on clinical study steering committees and giving lectures at congresses and other scientific sessions&#46; Dulce Brito has received fees from Novartis&#44; Orion&#44; Roche&#44; Servier&#44; St&#46; Jude and Vifor &#40;companies that develop and market tests and&#47;or treatments in the area of HF&#41; for HF consulting&#44; and has given talks at congresses and other scientific sessions&#46; She also reports consultancy and research fellowships from Genzyme-Sanofi and consultancy and lecture fees from Pfizer&#44; and has attended meetings sponsored by Shire Human Genetic Therapies &#40;companies that develop and market treatments in the area of cardiomyopathies&#41;&#46; Jorge Ferreira has received consulting and speaker fees from Amgen&#44; AstraZeneca&#44; Boehringer-Ingelheim&#44; MerckSharp &#38; Dohme&#44; Novartis&#44; and Orion&#46; F&#225;tima Franco has received consulting and speaker fees from Novartis&#46; Jo&#227;o Morais received honoraria within the last two years from pharmaceutical companies for consulting activities &#40;Bayer Healthcare&#44; Astra Zeneca&#44; Merck Sharp &#38; Dhome&#44; Novartis&#41; and fees for lectures &#40;Boehringer Ingelheim&#44; Bial&#44; Servier&#44; Daiichi Sankyo&#44; Boston Scientific&#41;&#46; He is also National Coordinator for the PARADISE-MI trial on sacubitril&#47;valsartan in patients with myocardial infarction&#46; Jos&#233; Silva Cardoso was national coordinator of the PARADIGM-HF study and was a consultant for Novartis&#44; AstraZeneca Pharmaceuticals&#44; Orion&#44; Pfizer&#44; Servier and Vifor &#40;companies that develop and market treatments for HF&#41;&#46; He has sat on steering committees for clinical studies sponsored by Novartis&#44; Orion and Pfizer and has received honoraria as a speaker in sessions on HF and research fellowships from Novartis&#44; Abbott&#44; AstraZeneca Pharmaceuticals&#44; Bial&#44; Boehringer Ingelheim&#44; Menarini&#44; Merck Serono&#44; Merck Sharp &#38; Dohme&#44; Orion&#44; Pfizer&#44; Sanofi&#44; Servier and Vifor&#46;</p></span></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">IN WHOM AND WHEN&#63;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Indications&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Adult patients with heart failure and reduced ejection fraction &#40;LVEF &#60;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Replacement of ACEI&#47;ARB in outpatients who remain in NYHA class II-IV despite treatment with an ACEI&#47;ARB&#44; a beta-blocker and an MRA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Before discharge&#44; in stabilized patients admitted with a primary diagnosis of decompensated or de novo acute heart failure&#44; irrespective of prior ACEI&#47;ARB exposure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Patients should have SBP &#8805;100 mmHg and serum potassium level &#60;5&#46;5 mmol&#47;l&#46;&nbsp;\t\t\t\t\t\t\n
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Letter to the Editor
Sacubitril/valsartan: A practical guide revisited
Sacubitril/valsartan: um guia prático revisitado
Cândida Fonsecaa,
Corresponding author
mcandidafonseca@gmail.com

Corresponding author.
, Dulce Britob, Jorge Ferreirac, Fátima Francod, João Moraise, José Silva Cardosof, Expert opinion endorsed by the Heart Failure Study Group of the Portuguese Society of Cardiology
a Clínica de Insuficiência Cardíaca, Serviço de Medicina III e Hospital Dia, Hospital São Francisco Xavier – Centro Hospitalar de Lisboa Ocidental, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
b Serviço de Cardiologia, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, CCUL, Faculdade de Medicina da Universidade de Lisboa, Portugal
c Hospital de Santa Cruz – Centro Hospitalar de Lisboa Ocidental, Serviço de Cardiologia, Portugal
d Hospital Universidade de Coimbra – Centro Hospitalar e Universitário de Coimbra, Serviço de Cardiologia, Coimbra, Portugal
e Centro Hospitalar de Leiria, Serviço de Cardiologia, Leiria, Portugal
f Clínica de Insuficiência Cardíaca e Transplante, Centro Hospitalar de São João, Serviço de Cardiologia, Faculdade de Medicina da Universidade do Porto, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Since the publication in the May 2019 issue of our paper &#8220;Sacubitril&#47;valsartan&#58; a practical guide&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> which was based on the PARADIGM-HF<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> trial results&#44; new evidence has become available with recent data from the TRANSITION and PIONEER-HF trials&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> On the basis of this new evidence&#44; as the authors of the original practical guide we would like to add new considerations to our previous recommendations on the use of this drug&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although it represents a worsening of prognosis in heart failure with reduced ejection fraction &#40;HFrEF&#41;&#44; hospitalization for acute heart failure constitutes an opportunity to initiate and successfully up-titrate guideline-recommended therapies&#46; The international guidelines support the initiation and up-titration of all disease-modifying therapy &#40;DMT&#41; early after hemodynamic stabilization following an acute heart failure event in order to improve prognosis&#44; particularly during the vulnerable phase early after discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> Although this has been demonstrated for previous classes of heart failure DMT&#44; there was still a gap in evidence on the optimal time for the initiation of sacubitril&#47;valsartan in HFrEF patients after an acute decompensation&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The TRANSITION and PIONEER-HF trials evaluated the initiation of sacubitril&#47;valsartan in severe HFrEF patients after stabilization following an acute heart failure episode&#44; both before and early after discharge&#44; with no run-in phase&#44; closer to the challenges of everyday clinical practice&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The TRANSITION study assessed the safety and tolerability of sacubitril&#47;valsartan in patients admitted with HFrEF&#44; after stabilization following an acute heart failure episode&#46; Patients were enrolled to initiate sacubitril&#47;valsartan either in the hospital or shortly after discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> At 10 weeks&#44; when more than 86&#37; of patients had been receiving sacubitril&#47;valsartan for two weeks or longer without interruption&#44; about half the patients in the study had achieved the primary endpoint&#44; which was a target dose of 200 mg of sacubitril&#47;valsartan twice daily within 10 weeks in both groups&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> The incidence of adverse events and discontinuation of sacubitril&#47;valsartan due to adverse events was also similar in both in-hospital and outpatient settings&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> The tolerability of sacubitril&#47;valsartan in TRANSITION appears to be comparable to that reported for beta-blockers and ACEIs&#47;ARBs under real-life conditions&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">PIONEER-HF was designed to assess the safety&#44; tolerability and efficacy of in-hospital initiation of sacubitril&#47;valsartan compared to enalapril in stabilized HFrEF patients who had been admitted for acute decompensation&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The primary endpoint was the time-averaged proportional change in NT-proBNP from baseline through weeks 4 and 8&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">4&#44;8</span></a> Patients treated with sacubitril&#47;valsartan achieved a 47&#37; reduction from baseline in time-averaged NT-proBNP&#44; compared to a 25&#37; reduction with enalapril&#44; translating into a statistically significant 29&#37; greater reduction with sacubitril&#47;valsartan over the ACEI &#40;95&#37; CI&#58; 0&#46;63-0&#46;81&#59; p&#60;0&#46;0001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Significant reductions in NT-proBNP were observed in sacubitril&#47;valsartan patients as early as one week after treatment initiation&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> There were no new safety signals identified&#44; and the safety profile was comparable to that observed in PARADIGM-HF&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2&#44;4</span></a> Rates of serious adverse events occurring with a frequency of &#8805;0&#46;5&#37; were similar between the sacubitril&#47;valsartan and enalapril groups&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In a pre-specified exploratory analysis&#44; the composite endpoint of death&#44; rehospitalization for HF&#44; left ventricular assist device implantation or listing for cardiac transplant occurred in 41 &#40;9&#46;3&#37;&#41; patients in the sacubitril&#47;valsartan group and in 74 &#40;16&#46;8&#37;&#41; in the enalapril group &#40;HR 0&#46;54&#44; 95&#37; CI 0&#46;37-0&#46;79&#59; p&#61;0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> The benefit was driven by reductions in death and rehospitalization among patients treated with sacubitril&#47;valsartan&#46; The number needed to treat to prevent one such clinical event during eight weeks of follow-up was 13&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Moreover&#44; TRANSITION and PIONEER-HF are the first randomized studies to provide data on the use of sacubitril&#47;valsartan in new-onset and ACEI&#47;ARB-naive HFrEF patients&#46; In fact&#44; approximately 34&#37; of patients in PIONEER and 29&#37; in TRANSITION were newly diagnosed&#44; with no prior history of heart failure&#44; and slightly more than 50&#37; of patients in PIONEER and 24&#37; in TRANSITION were not receiving ACEI&#47;ARB therapy at the time of admission&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> Recently presented data from PIONEER-HF also showed that sacubitril&#47;valsartan&#44; titrated to target dose based on systolic blood pressure during hospitalization&#44; had the same beneficial effect on the primary and safety endpoints in ACEI&#47;ARB-naive patients&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In summary&#44; the TRANSITION and PIONEER-HF results provide complementary data to PARADIGM-HF&#44; addressing previous gaps in evidence&#46; They support the use of sacubitril&#47;valsartan both during hospital stay and in outpatient settings&#46; Although there are still a few unanswered questions and unpublished results from both trials&#44; the data from PIONEER-HF and TRANSITION support the in-hospital initiation of sacubitril&#47;valsartan in all NYHA II-III patients early after stabilization&#44; and independently of prior HF diagnosis or ACEI&#47;ARB exposure&#46; There are now grounds for initiating therapy in HFrEF with ACEI safely as a first option&#44; in both in-hospital and outpatient settings&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">On the basis of this new information&#44; our paper &#8220;Sacubitril&#47;valsartan&#58; a practical guide&#8221; should be revisited as in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">C&#226;ndida Fonseca has received fees from Amgen&#44; AstraZeneca&#44; Bayer&#44; Boehringer-Ingelheim&#44; Novartis&#44; Orion&#44; Roche&#44; Servier and Vifor &#40;companies that develop and market tests and&#47;or treatments in the area of HF&#41; for HF consulting&#44; sitting on clinical study steering committees and giving lectures at congresses and other scientific sessions&#46; Dulce Brito has received fees from Novartis&#44; Orion&#44; Roche&#44; Servier&#44; St&#46; Jude and Vifor &#40;companies that develop and market tests and&#47;or treatments in the area of HF&#41; for HF consulting&#44; and has given talks at congresses and other scientific sessions&#46; She also reports consultancy and research fellowships from Genzyme-Sanofi and consultancy and lecture fees from Pfizer&#44; and has attended meetings sponsored by Shire Human Genetic Therapies &#40;companies that develop and market treatments in the area of cardiomyopathies&#41;&#46; Jorge Ferreira has received consulting and speaker fees from Amgen&#44; AstraZeneca&#44; Boehringer-Ingelheim&#44; MerckSharp &#38; Dohme&#44; Novartis&#44; and Orion&#46; F&#225;tima Franco has received consulting and speaker fees from Novartis&#46; Jo&#227;o Morais received honoraria within the last two years from pharmaceutical companies for consulting activities &#40;Bayer Healthcare&#44; Astra Zeneca&#44; Merck Sharp &#38; Dhome&#44; Novartis&#41; and fees for lectures &#40;Boehringer Ingelheim&#44; Bial&#44; Servier&#44; Daiichi Sankyo&#44; Boston Scientific&#41;&#46; He is also National Coordinator for the PARADISE-MI trial on sacubitril&#47;valsartan in patients with myocardial infarction&#46; Jos&#233; Silva Cardoso was national coordinator of the PARADIGM-HF study and was a consultant for Novartis&#44; AstraZeneca Pharmaceuticals&#44; Orion&#44; Pfizer&#44; Servier and Vifor &#40;companies that develop and market treatments for HF&#41;&#46; He has sat on steering committees for clinical studies sponsored by Novartis&#44; Orion and Pfizer and has received honoraria as a speaker in sessions on HF and research fellowships from Novartis&#44; Abbott&#44; AstraZeneca Pharmaceuticals&#44; Bial&#44; Boehringer Ingelheim&#44; Menarini&#44; Merck Serono&#44; Merck Sharp &#38; Dohme&#44; Orion&#44; Pfizer&#44; Sanofi&#44; Servier and Vifor&#46;</p></span></span>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t"><span class="elsevierStyleBold">IN WHOM AND WHEN&#63;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Indications&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Adult patients with heart failure and reduced ejection fraction &#40;LVEF &#60;40&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Replacement of ACEI&#47;ARB in outpatients who remain in NYHA class II-IV despite treatment with an ACEI&#47;ARB&#44; a beta-blocker and an MRA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Before discharge&#44; in stabilized patients admitted with a primary diagnosis of decompensated or de novo acute heart failure&#44; irrespective of prior ACEI&#47;ARB exposure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>&#8226; Patients should have SBP &#8805;100 mmHg and serum potassium level &#60;5&#46;5 mmol&#47;l&#46;&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 21742049
Original language: English
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Idiomas
Revista Portuguesa de Cardiologia (English edition)
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