Vericiguat—Filling the Gaps in Heart Failure Management

Corresponding author: B Hygriv Rao, KIMS Hospitals, Hyderabad, Telangana 500003, India. E-mail: hygriv@hotmail.com Left ventricular dysfunction is an established marker in heart failure (HF) patients predicting poor clinical outcomes, sudden death, and overall mortality.1 Over the last few decades, various pharmacological agents as guideline directed medical treatment (GDMT) have been introduced serially in the management of HF resulting in incremental benefit in HF hospitalizations, quality of life, symptom alleviation, and mortality. Large data has established the use of beta blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor– neprilysin inhibitors, and mineralocorticoid receptor antagonists, in these patients. The ongoing battle against HF was consolidated by amalgamation of sacubitril–valsartan and SGLT-2 inhibitors in the GDMT by data from large trials—PARDIGM HF, DAPA HF, EMPEROR Reduced. 2,3,4 Despite the scintillating advances in pharmacotherapy in this area, the twin clinical problems of worsening HF and renal failure continue to cause abundant frustration in patient management. Patients with a recent HF hospitalization or worsening HF constitute a particularly vulnerable cohort as they are associated with high subsequent event rates and mortality. Moreover HF is frequently associated with impaired renal function and/or high serum potassium concentrations. Kidney is truly the Achilles heel in the management of HF as almost all the routine medications used in these patients require monitoring of renal function and electrolytes.5 Impaired estimated glomerular filtration rate (eGFR), with HF, presents a serious therapeutic challenge as it precludes prescription of all components of GDMT, makes it difficult to up-titrate them to optimal doses, and frequently results in their discontinuation. The most difficult cohort of patients to initiate and maintain GDMT are patients with a lower eGFR, higher N-terminal probrain natriuretic peptide (NTproBNP), and elevated serum potassium concentrations. These are the patients who have a higher risk of cardiovascular death and hospitalizations for HF and in a greater need for these treatments. Accordingly, an unmet need exists for effective therapies in patients with severe heart failure with reduced ejection fraction (HFrEF) and advanced chronic