Prolonged first-dose hypotension induced by sacubitril/valsartan

Entresto was recommanded by major guidelines as the frontline therapy for heart failure with reduced ejection fraction since its clinical benefit was proved by the PARADIGM-HF trial. Angiotensin converting enzyme inhibitors are the cornerstone of the treatment of HF. Varying incidences of first-dose hypotension have been reported and recognized as a potential limiting factor for prescribing. According to previous reports, the onset of hypotension mostly occur 3-5 hours after the first dose. However, the pattern of entresto-related hypotension has not been reported.We present a case of HF, who had delay onset (about 8 to 18 hours) and prolonged (3 to 6 days) first-dose hypotension. Further investigation is required to illustrate this phenomenon.