Early Initiation of Sacubitril/Valsartan in Intracerebral Hemorrhage With Refractory Hypertension and Chronic Heart Failure - A Case Report

Sep 30, 2026

Intracerebral hemorrhage (ICH) is a severe stroke subtype with high mortality and morbidity, and management is harder when complicated by major comorbidities such as chronic heart failure. Sacubitril/valsartan, an angiotensin receptor–neprilysin inhibitor, lowers blood pressure and may provide cardioprotective effects. In Japan it is approved for hypertension, but acute ICH use is rare. This case describes early, rapid titration after admission, achieving blood pressure control without hypotension and improving cardiac congestion markers.

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CategoryHealthcare

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Reading Time15 min

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Review began 11/13/2025 Review ended 12/05/2025 Published 12/10/2025 © Copyright 2025 Nishino et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98919 Open Access Case Report Early Initiation of Sacubitril/Valsartan in Intracerebral Hemorrhage With Refractory Hypertension and Chronic Heart Failure: A Case Report Takeru Nishino 1, Ayumu Yamaoka 1, Katsuya Komatsu 1, Yukinori Akiyama 1, Nobuhiro Mikuni 1 1. Department of Neurosurgery, Sapporo Medical University, School of Medicine, Sapporo, JPN Corresponding author: Ayumu Yamaoka, [a06m090@yahoo.co.jp](a06m090@yahoo.co.jp) Abstract Intracerebral hemorrhage (ICH) is a devastating type of stroke associated with high mortality and morbidity, and its management becomes more challenging when complicated by severe comorbidities such as chronic heart failure. Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor, was originally developed for chronic heart failure but has also demonstrated potent blood pressure-lowering effects. In Japan, sacubitril/valsartan has had an approved indication for hypertension, supported by multiple clinical trials, including the phase III study. However, its application in the acute management of ICH remains extremely limited. We report the case of a man in his 50s with right putaminal hemorrhage complicated by refractory hypertension and chronic heart failure. On admission, his blood pressure remained elevated despite continuous intravenous nicardipine infusion at 11 mg/h and additional nitroglycerin. He subsequently required a combination of five antihypertensive agents. Following surgical evacuation of the hematoma, we transitioned his therapy to oral agents on day two. By initiating and rapidly titrating sacubitril/valsartan, we achieved effective blood pressure control without causing hypotension. In addition, the patient’s significantly elevated N-terminal pro-B-type natriuretic peptide level decreased from 1823 to 272 pg/mL, accompanied by dramatic improvements in cardiac size and pulmonary congestion. The clinical course suggests that sacubitril/valsartan offers a unique dual benefit in this high-risk patient population: it not only provides effective blood pressure control but also delivers crucial cardioprotective effects. This report highlights its potential as a game-changing therapeutic option, particularly during the critical transition from intravenous to oral therapy in acute ICH. Categories: Cardiology, Emergency Medicine, Neurosurgery Keywords: cerebral hemorrhage, chronic heart failure, perioperative blood pressure management, refractory hypertension, sacubitril/valsartan Introduction Intracerebral hemorrhage (ICH) remains a devastating form of stroke, with reported mortality rates of 30% to 40% and substantial risk of enduring neurological deficits [1] . The presence of severe comorbidities such as heart failure further complicates acute-phase management and worsens the overall prognosis [2] . Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor, was originally developed as a treatment for chronic heart failure but has recently gained attention for its blood pressure-lowering effects [3] . In Japan, sacubitril/valsartan has had an approved indication for hypertension since September 2021, supported by multiple clinical trials, including the phase III study [4,5] . The 2025 Japanese Society of Hypertension Guidelines also mention sacubitril/valsartan as a therapeutic option for selected hypertensive patients, particularly those with concomitant cardiac disease [6] . However, its use in the acute antihypertensive management of stroke, particularly ICH, remains very limited. Here, we present a case of ICH complicated by refractory hypertension and chronic h

FAQs

Why is early blood pressure management difficult in intracerebral hemorrhage with chronic heart failure?

ICH already carries high mortality and morbidity, and severe comorbidities like chronic heart failure worsen acute-phase management and prognosis.

What treatment strategy was used in the reported case?

The patient’s blood pressure remained high despite continuous intravenous nicardipine and additional nitroglycerin, requiring multiple antihypertensive agents, followed by early oral sacubitril/valsartan titration after surgery.

What clinical effects were observed after initiating sacubitril/valsartan?

Effective blood pressure control was achieved without causing hypotension, and N-terminal pro-B-type natriuretic peptide levels decreased alongside marked improvements in cardiac size and pulmonary congestion.

Sep 30, 2026

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