PEBC MCQ Heart Failure, AF, CAD & Anticoagulation question: cardiologist switches CP from ramipril

PEBC MCQHeart Failure, AF, CAD & Anticoagulation

The cardiologist switches CP from ramipril 5 mg twice daily to sacubitril/valsartan. CP took his last ramipril dose at 08:00 today. When is the earliest he can take the first sacubitril/valsartan dose?

a. At 08:00 tomorrow
b. At 20:00 tomorrow
c. At 08:00 in 3 days
d. At 20:00 today

Show the answer and explanation

Answer: b. At 20:00 tomorrow

Sacubitril/valsartan must not be started until 36 hours after the last ACE inhibitor dose because combined neprilysin and ACE inhibition sharply raises the risk of angioedema. From 08:00 today, 36 hours later is 20:00 tomorrow. Starting this evening or tomorrow morning is too early, and waiting 3 days delays therapy without benefit. No washout is needed when switching from an ARB. Source: Sacubitril/valsartan (Entresto) product monograph, Contraindications and Dosage: 36-hour ACE inhibitor washout (DPD, checked 2026); CCS/CHFS HF guidelines update (Can J Cardiol 2021;37:531).

Common mistake

Starting the ARNI too soon after an ACE inhibitor.

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