Sacubitril/Valsartan in Advanced Heart Failure with Reduced Ejection Fraction: Rationale/Design of the LIFE Trial

Mann, Douglas L.; Greene, Stephen J.; Givertz, Michael M.; Vader, Justin M.; Starling, Randall C.; Ambrosy, Andrew P.; Shah, Palak; McNulty, Steven E.; Mahr, Claudius; Gupta, Divya; Redfield, Margaret M.; Lala, Anuradha; Lewis, Gregory D.; Mohammed, Selma F.; Gilotra, Nisha A.; DeVore, Adam D.; Gorodeski, Eiran Z.; Desvigne-Nickens, Patrice; Hernandez, Adrian F.; Braunwald, Eugene

Abstract The PARADIGM-HF trial reported that sacubitril/valsartan (S/V), an angiotensin receptor-neprilysin inhibitor, significantly reduced mortality and heart failure (HF) hospitalization in HF patients with a reduced ejection fraction (HFrEF). However, fewer than 1% of patients in PARADIGM-HF had NYHA class IV symptomology; accordingly, data that informs the use of S/V among patients with advanced HF are limited. The LIFE (LCZ696 In Hospitalized Advanced Heart FailurE) study is a 24-week prospective, multicenter, double-blinded, double-dummy, active-comparator trial to assess the safety, efficacy and tolerability of S/V compared with V in patients with advanced HFrEF. The trial planned to randomize 400 patients age ≥18 years with advanced HF, defined as an EF ≤35%, NYHA functional class IV symptoms, elevated natriuretic peptide concentration (B-type natriuretic peptide [BNP] ≥250 pg/mL or N-terminal-pro-B-type natriuretic peptide [NT-proBNP] ≥800 pg/mL), and ≥1 objective finding(s) of advanced HF. Following a 3-7 day open-label run-in period with S/V 24/26 mg twice daily, patients are randomized 1:1 to S/V titrated to 97/103 mg twice daily versus 160 mg V twice daily. The primary endpoint is the proportional change from baseline in the area under the curve for NT-proBNP levels measured through week 24. Secondary and tertiary endpoints include clinical outcomes, as well as safety and tolerability. Because of the COVID-19 pandemic enrollment in the LIFE trial was stopped prematurely to ensure patient safety and data integrity. The primary analysis will consist of the first 335 randomized patients, whose clinical follow-up was not severely impacted by COVID-19.