Global trend and predictors of non-labelled sacubitril-valsartan dosing: results from IKNOW-HF survey

Abstract

Background and Aims Optimizing guideline-directed medical therapy (GDMT) remains vital for heart failure (HF) management. However, non-labelled dosing of sacubitril-valsartan is increasingly reported. This global survey characterized real-world sacubitril-valsartan prescribing patterns and evaluated pharmacist involvement in HF teams.Background and Aims Optimizing guideline-directed medical therapy (GDMT) remains vital for heart failure (HF) management. However, non-labelled dosing of sacubitril-valsartan is increasingly reported. This global survey characterized real-world sacubitril-valsartan prescribing patterns and evaluated pharmacist involvement in HF teams.Methods The validated 26-item IKNOW-HF survey was disseminated globally to clinicians treating patients with HF. Participation was voluntary and anonymous.Results Out of 1829 responses from 76 countries, 1285 (70.3%) were complete, predominantly from cardiologists 1031 (80.2%). Non-labelled sacubitril-valsartan dosing was reported by 1107 (86.1%) respondents, heavily driven by general cardiologists 326 (90%) and clinicians in the low- and lower-middle-income countries 195 (96%). Predictors of non-labelled dosing included practicing in Asia [odds ratio (OR) 0.347; 95% confidence interval (CI) (0.214-0.563)] and having over 10 years of experience [OR 0.695; 95% CI (0.489-0.990)]. The presence of a cardiology pharmacist trended towards a fewer non-labelled prescriptions [OR 0.542; 95% CI (0.283-1.039), P-value = 0.065], whereas management by HF specialist trended towards increased non-labelled usage [OR 1.443; 95% CI (0.981-2.122), P-value = 0.063].Conclusions The IKNOW-HF survey reveals a substantial variation between guideline-recommended and real-world prescribing practices, with over 80% of responding clinicians utilizing non-labelled dosing. The higher prevalence among HF specialists likely reflects a pragmatic salvage strategy for advanced HF patients intolerant to standard target doses. These findings highlight the need for further education, pragmatic clinical trials evaluating real-world dosing outcomes, and broader integration of specialized pharmacists to optimize GDMT.