Practical considerations for the use of vericiguat in older patients with heart failure and reduced ejection fraction

Worsening heart failure (WHF) is a red flag in the natural history of heart failure (HF) that negatively impacts the prognosis. Urgent improvements in the management of WHF, especially among HF with reduced ejection fraction (HFrEF) patients, are needed to reduce morbidity and mortality.

Vericiguat is an oral soluble guanylate cyclase (sGC) stimulator that was able to reduce the composite of HF hospitalization or cardiovascular (CV) death in the VICTORIA trial and is now recommended with a IIb indication by HF guidelines of different societies. Accordingly, several observational studies confirmed the positive findings observed in the trial. Since the population with HFrEF includes a large number of older patients with multiple comorbidities and different degrees of frailty, implementation and up-titration of guideline-directed medical treatments (GDMTs) could be challenging due to a higher odd of side effects. To this end, vericiguat possesses many advantages: once daily administration, good tolerance, limited side effects (e.g. hypotension), no need for routine laboratory testing or therapeutic drug monitoring. This makes vericiguat a good candidate for older, frail patients in order to increase patient compliance and limit drug discontinuation caused by side effects.

Although commonly named as the fifth pillar of GDMTs, vericiguat should be considered as soon as possible among those patients with HFrEF and a WHF episode. However, the recently published VICTOR trial has investigated the effect of vericiguat in HFrEF patients who did not experience a recent WHF and did not demonstrate a reduction in the composite outcome of HF hospitalization or CV death, while providing beneficial effects on CV and all-cause mortality.