OBJECTIVES: In the updated European Society of Cardiology guidelines for heart failure with reduced ejection fraction (HFrEF) (ESC2021), angiotensin receptor neprilysin inhibitors (ARNI) are included as a first-line treatment option. Nonetheless, ARNIs are currently reimbursed in Norway as later-line treatment, substituting angiotensin-converting enzyme inhibitors or angiotensin-receptors blockers (ACEi/ARB) in symptomatic patients. This causes a misalignment between the international recommendations and clinical practice in Norway. The objective of this study was to estimate the budgetary and health impact of increasing the use of ARNI in first line HFrEF treatment as a consequence of implementing and adhering to the updated international guidelines in Norway.

METHODS: An economic model was developed to compare conventional care to an interpretation of the ESC2021 HFrEF treatment guideline where an increased proportion of patients receive ARNI first line (40%). Incident cohorts were included on an annual basis and followed over ten years. Treatment specific all-cause mortality, hospitalization rate and distributions of patients among treatments were informed by literature and clinical experts. Drug acquisition, monitoring, and hospitalization costs were derived from publicly available sources.

RESULTS: Based on our analysis, increasing the use of ARNI could lead to budget savings of more than 123 million NOK in 10 years. The predicted increase in drug acquisition and monitoring costs of approximately 162 and 7 million NOK, would be balanced by the 651 hospitalizations avoided, translating into a decrease in hospitalizations costs of 46 million NOK. In addition, 208 deaths could be postponed, with 1,165 total life-years gained.

CONCLUSIONS: Increasing the use of ARNI is expected to decrease the healthcare expenditure while having major health impacts on HFrEF patients, as well as making a significant amount of healthcare resources available for alternative use in Norway.