Current heart failure guidelines recommend using 4 heart failure drugs simultaneously in patients with chronic heart failure and reduced ejection fraction to get the best results. There could be in fact a 74% reduction in mortality if all 4 drugs are employed; these are a beta blocker, an ACEI or ARNI, an MRA and an SGLT2inhibitor.
The American guidelines mention briefly that in the event of worsening heart failure despite guideline mandated therapy a new drug named vericiguat be used as the Victoria Trial has reported a significant 10% reduction in the primary end point of cardiovascular mortality or heart failure admission in the cohort randomised to vericiguat as compared to placebo.
The Victoria Trial studied 5050 patients of chronic heart failure with educed ejection fraction who worsened in the previous 6 months ( needed hospital admission or injection of a diuretic). The median ejection fraction was 29%, there were 76% males, almost 90% were on 2 guideline medication, while 60% were on triple heart failure drugs. There was modest clinical improvement in a flow up of slightly more than 10 months, with he curve diverging at 3 months.
The dose used was 2.5 mg orally once a day to be titrated to 10 mg once a day.
One tablet of 2.,5 mg vericiguat costs about Rupees 100 in India.
A sub analyses presented in the ACC Meeting this year highlighted that vericiguat was most effective in the cohort of patients with an LV ejection fraction below 24%.
There were more cases of symptomatic hypotension, syncope and anaemia in the vericiguat group but kidney function and electrolytes were unaffected.
I would use the the 4 heart failure medicines mentioned above , before administering vericuguat in a patient with heart failure and reduced ejection fraction (HFrEF).
Also, it cannot be emphasised that despite the American Heart Association recommending vericiguat in worsening heart failure , there was no significant reduction in mortality in the treated group, albeit follow up was less than 11 months.