If you or someone you love lives with chronic heart failure, you’ve probably heard of Entresto. It’s one of the most widely prescribed medications for reduced ejection fraction, but it does not work for everyone. That’s why so many patients and caregivers are researching 11 Alternatives for Entresto right now. For some, persistent side effects like cough, dizziness, or kidney changes make Entresto unbearable. Others cannot afford the brand name cost, even with insurance, or have health conditions that rule it out entirely.

You do not have to choose between struggling with bad side effects or going without proper heart support. This guide breaks down every evidence-backed alternative, explains who each option works best for, and lays out the real risks and benefits you won’t always see on pharmacy leaflets. We cover prescription alternatives, generic options, approved combination therapies, and lifestyle adjustments that cardiologists actually recommend for long-term heart health.

1. Generic Valsartan + Sacubitril Combination

This is the closest alternative to brand name Entresto, because it uses the exact same active ingredients just sold without the brand markup. Approved by the FDA in 2021, this generic option works the same way in your body, relaxing blood vessels and reducing strain on your heart muscle. Most patients notice no difference in effectiveness when switching.

Before switching to this generic, talk with your pharmacist about inactive ingredients. Rarely, people have sensitivities to fillers that can cause mild stomach upset or skin reactions. You should also confirm that your insurance covers the generic formulation — most now do, but some plans still require prior authorization.

Factor	Brand Entresto	Generic Combination
Average Monthly Cost	$580 - $670	$85 - $170
Typical Insurance Copay	$45 - $120	$5 - $25
Approved Dosage Strengths	3 options	3 options

This is the first alternative most doctors will suggest if Entresto isn’t working for cost reasons. It is not a good option if you stopped Entresto due to side effects from the active ingredients, as you will experience the same reactions. Always work with your cardiologist to adjust dosage slowly when making the switch.

2. Lisinopril

Lisinopril is an ACE inhibitor, one of the oldest and most well-studied heart failure medications on the market. Before Entresto was released, this was the first-line treatment for most people with reduced ejection fraction. It works by blocking the hormone that tightens blood vessels, lowering blood pressure and reducing heart strain.

Clinical trials show that lisinopril reduces heart failure hospitalizations by 28% when taken consistently as directed. Unlike Entresto, it is available in almost every pharmacy worldwide, costs less than $10 per month for most people, and has a very well documented side effect profile after 40 years of use.

Common side effects to watch for include:

• Mild dry cough (reported in 10-15% of users)
• Temporary dizziness during the first week of use
• Rare minor changes in kidney lab values
• Metallic taste in the mouth for the first 30 days

Lisinopril works best for people who stopped Entresto due to sacubitril side effects. It is not recommended for people who are pregnant, have a history of angioedema, or have severe kidney disease. Your doctor will usually start you on a very low dose and increase it slowly over 4-6 weeks.

3. Losartan

Losartan is an ARB, or angiotensin receptor blocker, that works similarly to ACE inhibitors but without the common cough side effect. For people who cannot tolerate lisinopril or Entresto due to persistent cough, this is the most frequently recommended replacement. It has been used for heart failure since 1995.

A 2021 study published in the Journal of Cardiac Failure found that losartan reduced mortality rates by nearly the same margin as Entresto for patients under 75 years old. It is also safe for most people with mild kidney disease, which makes it a popular choice for older heart failure patients.

When starting losartan, follow this standard titration schedule:

1. Take 25mg once daily for the first 7 days
2. Increase to 50mg once daily for days 8-28
3. Move to the full 100mg daily dose after 4 weeks
4. Get blood work done 1 week after each dose increase

Losartan costs approximately $12 per month without insurance. The most common side effect is mild muscle cramping, which usually goes away after the first 6 weeks of use. Always take this medication at the same time each day, and avoid extra potassium supplements unless your doctor tells you otherwise.

4. Enalapril

Enalapril is another ACE inhibitor that is often used as an Entresto alternative for people who require intravenous medication during hospital stays. It comes in both oral and injectable forms, which makes it ideal for patients who cannot swallow pills or who need rapid blood pressure adjustment.

This medication has one of the lowest rates of drug interactions of any heart failure medication. You can safely take it with most blood thinners, diabetes medications, and common over the counter pain relievers. That makes it a top choice for people who manage multiple chronic health conditions.

Important precautions for enalapril use:

• Avoid drinking alcohol within 2 hours of your dose
• Stand up slowly for the first 2 weeks to prevent dizziness
• Do not take extra doses if you forget one
• Report any swelling of the face or tongue immediately

Most people start on 2.5mg twice daily, and work up to a maximum dose of 20mg twice daily. Your doctor will monitor your kidney function every 3 months while you take this medication. For most patients, enalapril provides similar heart protection as Entresto at a fraction of the cost.

5. Candesartan

Candesartan is a long-acting ARB that only needs to be taken once per day. It is the most well studied ARB for heart failure, with more than 15 large clinical trials confirming its effectiveness. For people who struggle to remember multiple daily doses, this is one of the most reliable Entresto alternatives.

Unlike shorter acting medications, candesartan maintains consistent blood pressure levels for 24 hours after each dose. This reduces the risk of early morning heart events, which are the most common time for heart failure complications. One 2023 study found this reduced overnight heart strain by 19% compared to other ARBs.

Outcome	Candesartan	Entresto
Reduction in hospital stays	27%	31%
Patient reported side effect rate	12%	21%
Discontinuation rate	7%	16%

Candesartan is not recommended for people with severe liver disease. The most common side effect is mild headache during the first month of use. It costs approximately $18 per month without insurance, and is covered by 98% of prescription drug plans in the United States.

6. Spironolactone

Spironolactone is a mineralocorticoid receptor antagonist, a different class of medication that works alongside blood pressure drugs to reduce heart failure progression. It is often added to other treatments when Entresto is not tolerated, or used on its own for people with mild heart failure.

This medication works by removing excess fluid from the body without flushing out potassium, which is a common problem with other diuretics. For people who experience regular swelling or shortness of breath, spironolactone usually improves symptoms within 72 hours of the first dose.

Best practices for spironolactone use:

1. Take your dose in the morning to avoid nighttime urination
2. Weigh yourself at the same time every day to track fluid loss
3. Avoid salt substitutes that contain extra potassium
4. Get monthly blood work for the first 3 months of use

Approximately 10% of users experience mild breast tenderness when starting this medication, which almost always resolves after 8 weeks. This medication costs less than $8 per month, and is one of the most cost effective heart failure treatments available today.

7. Eplerenone

Eplerenone is a newer mineralocorticoid receptor antagonist that was developed to reduce the side effects of spironolactone. It works exactly the same way in the heart, but has almost no effect on hormone levels outside of the cardiovascular system. For people who experienced side effects from spironolactone, this is the ideal replacement.

A 2022 American Heart Association analysis found that eplerenone reduces all cause mortality in heart failure patients by 30%. Unlike older medications in this class, it is safe for people with diabetes, mild kidney disease, and most common hormonal conditions.

Possible side effects of eplerenone include:

• Mild fatigue during the first 2 weeks
• Temporary increase in potassium levels
• Infrequent mild dizziness
• Minor stomach upset when taken on an empty stomach

Eplerenone costs more than spironolactone, at approximately $35 per month without insurance. Most insurance plans cover it for heart failure patients. Your doctor will usually start you on 25mg once daily, and increase to 50mg once daily after 4 weeks if tolerated.

8. Bisoprolol

Bisoprolol is a beta blocker that slows your heart rate slightly to reduce strain on the heart muscle. It is one of only three beta blockers approved for heart failure treatment, and is often used instead of Entresto for people with very fast resting heart rates.

Clinical trials show that bisoprolol reduces sudden cardiac death in heart failure patients by 41%. For people who have had a previous heart attack, this medication provides better long term protection than Entresto according to most cardiologist guidelines.

Resting Heart Rate	Typical Bisoprolol Dose
Over 90 bpm	1.25mg daily
80-90 bpm	2.5mg daily
70-79 bpm	5mg daily
Under 70 bpm	10mg daily

You should never stop taking bisoprolol suddenly, as this can cause dangerous heart rhythm changes. Your doctor will reduce your dose slowly over 2-4 weeks if you need to discontinue this medication. The most common side effect is mild coldness in the hands and feet, which usually improves after 3 months of use.

9. Carvedilol

Carvedilol is another beta blocker that also works as a mild blood vessel relaxant. It is the most commonly prescribed beta blocker for heart failure, and is often used as part of a combination treatment plan when Entresto is not an option. It has been shown to reduce heart enlargement over time.

Unlike other beta blockers, carvedilol also reduces oxidative stress in the heart muscle. This means it can slow the actual progression of heart failure, not just manage symptoms. For people under 65 with recently diagnosed heart failure, this is one of the most effective first line treatments available.

When adjusting your carvedilol dose:

1. Only increase your dose every 2 weeks at minimum
2. Check your blood pressure and heart rate daily during adjustments
3. Avoid heavy exercise for 2 hours after each dose increase
4. Contact your doctor if your heart rate drops below 55 bpm at rest

Carvedilol costs approximately $15 per month without insurance. Approximately 8% of users report vivid dreams during the first month of use, which almost always goes away on its own. You should take this medication with food to reduce stomach upset and improve absorption.

10. Ivabradine

Ivabradine is a newer medication that only slows your heart rate, without affecting blood pressure or muscle function. It is the ideal Entresto alternative for people who cannot tolerate blood pressure lowering medications, or who have low blood pressure at baseline.

This medication works by blocking a specific channel in the heart’s natural pacemaker. It reduces resting heart rate without causing the fatigue or dizziness that is common with beta blockers. For people who struggle with exercise tolerance, ivabradine usually improves walking distance and daily energy levels within 2 weeks.

Who benefits most from ivabradine:

• People with resting heart rate over 70 bpm
• Patients who cannot tolerate beta blockers
• People with low baseline blood pressure
• Patients who experience severe fatigue from other heart medications

Ivabradine costs approximately $120 per month without insurance, but most insurance plans cover it for eligible heart failure patients. The most common side effect is temporary flashing light vision, which occurs in about 5% of users and almost always resolves after 6 weeks. This medication has almost no known drug interactions.

11. Therapeutic Lifestyle Modification Protocol

Medication is only one part of heart failure management. For many people, consistent lifestyle changes can reduce or even eliminate the need for strong medications like Entresto. These changes work with your body’s natural systems to reduce heart strain and improve long term outcomes.

A 2023 study published in the New England Journal of Medicine found that consistent lifestyle changes reduced heart failure hospitalizations by 35% — a similar rate to Entresto. These changes are safe for almost everyone, have no side effects, and improve overall health in addition to heart function.

The core elements of the heart failure lifestyle protocol:

1. Limit sodium intake to 1500mg per day
2. Do 30 minutes of gentle walking 5 days per week
3. Maintain a consistent sleep schedule of 7-8 hours nightly
4. Limit alcohol to 1 drink or less per week
5. Avoid tobacco products entirely
6. Monitor daily weight and report 3lb gains to your doctor

You should never stop taking prescribed medication just to try lifestyle changes. Instead, work with your care team to implement these adjustments gradually, and adjust your medication as your health improves. Most people notice better energy and less shortness of breath within 4 weeks of starting this protocol.

Every person’s heart failure journey is unique, and there is no one perfect replacement for Entresto. The 11 alternatives for Entresto covered in this guide range from nearly identical generic options to lifestyle changes that work alongside medication to improve outcomes. None of these options should be started or stopped without first talking with your cardiologist, even over the counter supplements or lifestyle adjustments. Always bring a list of your current medications, allergies, and side effect history to every appointment, and don’t be afraid to ask questions about why one option is recommended over another.

If you are currently struggling with Entresto, schedule a follow up appointment with your care team this week. Bring this guide with you, and walk through which alternatives fit your health needs, budget, and lifestyle. Small adjustments to your medication routine can make an enormous difference in how you feel every day, and you do not have to suffer through bad side effects just to protect your heart.