Heart failure drugs: sacubitril-valsartan transition: practice question

A Pharmacology question in the style of the NEET PG paper. Answer it first, then read why the right option is right and why each of the others is wrong.

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Pharmacology · Heart failure drugs: sacubitril-valsartan transition

Sample item

A 64-year-old man with symptomatic HFrEF on enalapril is to be switched to sacubitril-valsartan. Which instruction is correct?

AStart sacubitril-valsartan the same day and continue enalapril for a weekBStop enalapril and wait at least 36 hours before the first dose, to avoid angioedemaCWait 7 days because enalapril causes prolonged hyperkalaemiaDSwitch directly because both drugs only reduce afterload

Original practice item, not a recalled exam question. Nothing here is recorded.

The answer and the reasoning

B. Stop enalapril and wait at least 36 hours before the first dose, to avoid angioedema

Sacubitril inhibits neprilysin and valsartan blocks the AT1 receptor. Neprilysin and ACE both degrade bradykinin, so combining the two raises bradykinin markedly and increases the risk of angioedema. A washout of at least 36 hours after the last ACE inhibitor dose is therefore required before starting.

Option by option

A. Start sacubitril-valsartan the same day and continue enalapril for a week
Overlap with an ACE inhibitor is contraindicated because of angioedema risk.
B. Stop enalapril and wait at least 36 hours before the first dose, to avoid angioedema (correct)
Correct. A 36-hour ACE inhibitor washout lowers the risk of bradykinin-mediated angioedema.
C. Wait 7 days because enalapril causes prolonged hyperkalaemia
The washout is based on bradykinin, not on potassium, and 36 hours is sufficient.
D. Switch directly because both drugs only reduce afterload
The two drugs do not simply share an effect on afterload; neprilysin inhibition adds a bradykinin risk.

Source note: Original NextPrep sample item — pending expert review. This item is original practice material awaiting independent expert review, so confirm important facts in a standard textbook.

Questions about this Pharmacology question

What is the answer to this Pharmacology question?

The best answer is B, Stop enalapril and wait at least 36 hours before the first dose, to avoid angioedema. Sacubitril inhibits neprilysin and valsartan blocks the AT1 receptor.

Why is "Start sacubitril-valsartan the same day and continue enalapril for a…" not the answer?

Overlap with an ACE inhibitor is contraindicated because of angioedema risk.

Why is "Wait 7 days because enalapril causes prolonged hyperkalaemia" not the answer?

The washout is based on bradykinin, not on potassium, and 36 hours is sufficient.

Why is "Switch directly because both drugs only reduce afterload" not the answer?

The two drugs do not simply share an effect on afterload; neprilysin inhibition adds a bradykinin risk.

What concept does this question test?

It tests Heart failure drugs: sacubitril-valsartan transition in Pharmacology. Neprilysin and ACE both degrade bradykinin, so combining the two raises bradykinin markedly and increases the risk of angioedema. A washout of at least 36 hours after the last ACE inhibitor dose is therefore required before starting.

How hard is this question?

We tag it as a multi-step question: it asks you to combine more than one idea. The tag is our own editorial judgement, not an official difficulty rating, so read the reason for every option, not only the answer.

How should I study Heart failure drugs: sacubitril-valsartan transition?

Learn drugs as classes, then the exception in each class that an examiner would pick. Then use the flashcards and the other Pharmacology questions on this site to test what stuck.

Is this a real NEET PG question?

No. It is an original practice item (editorial status: sample, version 1). NextPrep does not publish recalled or leaked questions, and independent faculty review of this item has not been completed yet, so confirm important facts in a standard textbook.