Beyond the primary endpoint: what VICTOR really tells us about vericiguat

The VICTOR trial evaluated vericiguat in stable, ambulatory HFrEF patients without recent WHF. Its primary composite endpoint of CV death or HF hospitalization resulted neutral. Yet, a significant reduction in CV mortality was observed.

We analyzed the results of the VICTOR trial and put them in the broader context of HFrEF, where anticipating WHF events remains a mandatory task to improve the overall prognosis. We discussed oral diuretic intensification (ODI), that should represent an important aspect to be considered in stable HFrEF patients.

Outpatient WHF events are common in well-treated HFrEF patients and future HF trials should consider to regularly capture ODI. Although secondary endpoint analyses should be interpreted as nominal, the reduction in CV mortality in the VICTOR trial cannot be explained solely through prevention of HF progression or an effect on neurohormonal activation and hemodynamic stress. While current evidence for vericiguat is largely derived from patients with recent WHF, as shown in the VICTORIA trial, the findings of the VICTOR trial might provide a rationale for considering vericiguat earlier in the HFrEF treatment pathway, rather than limiting its use exclusively to patients who fail or progress despite quadruple therapy.