Page 53 - ITPS-8-2

INNOSC Theranostics and
Pharmacological Sciences Management of heart failure in Pakistan

combination of both. HF affects an average of 64.3 million driven by a reduction in HF hospitalization, over a median
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people worldwide, making it a significant global cardiac follow-up of 10.8 months. Table 1 summarizes the key
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pathology. As the population ages and the outcomes of outcomes of the VICTORIA trial, comparing Vericiguat
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acute cardiovascular events improve, the prevalence of HF and placebo groups in terms of cardiovascular events,
has increased. Despite new therapies and management mortality, and adverse effects. However, the reduction in
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strategies, individuals with HF still face a poor prognosis, cardiovascular death was not statistically significant (16.4%
with a 5-year survival rate estimated at around 50% following vs. 17.5%; hazard ratio, 0.93 [95% confidence interval,
the initial diagnosis. Recurrent hospital stays and the need 0.81–1.06]). This suggests that vericiguat is particularly
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for additional parenteral therapy during exacerbations beneficial for HFrEF patients with worsening symptoms
further indicate worse prognoses and lower quality of life. who remain clinically unstable despite being on guideline-
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HF with reduced ejection fraction (HFrEF) is a condition directed medical therapy (GDMT), as evidenced by high
where the heart is unable to pump enough blood to meet NT-proBNP levels and frequent hospital admissions. The
the body’s needs due to an inability of the left ventricle to findings of the VICTORIA study can be contrasted with
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contract sufficiently. This leads to clinical manifestations those of the EMPEROR-Reduced study, which focused
such as shortness of breath and fatigue. Ejection fraction on a slightly different patient population. The EMPEROR-
(EF), which measures the amount of blood pumped out Reduced study included patients with a broader range
with each contraction, is normally 55% and above, whereas of baseline ejection fractions and NT-proBNP levels,
HFrEF is defined by an ejection fraction of 40% or less. The which may explain the different outcomes observed
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HF is categorized into HF with preserved ejection fraction between the studies. In addition, the treatment protocols
(HFpEF, ejection fraction ≥50%), mid-range ejection in the EMPEROR-reduced study emphasized the
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fraction (HFmrEF, EF: 40 – 49%), and reduced ejection comprehensive use of GDMT, whereas, in the VICTORIA
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fraction (HFrEF, ejection fraction ≤40%). HFrEF poses trial, a significant portion of the cohort was not optimally
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a significant health challenge globally and is particularly managed according to current guidelines. This discrepancy
prevalent in Pakistan, where approximately 2.8 million highlights the need for precise patient selection and
people are affected by congestive heart failure (CHF). The optimization of background therapy when evaluating the
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prevalence of CHF is higher in urban areas and among efficacy of novel treatments like vericiguat in real-world
older adults, driven by high rates of diabetes, hypertension, settings. Evidence from the VICTORIA study, supported
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and obesity. In Pakistan, HFrEF management involves a by additional analyses, suggests that the ideal candidates
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combination of lifestyle modifications – such as quitting for vericiguat are HFrEF patients with an ejection fraction
smoking, exercising regularly, and adhering to a healthy of 40% or less, elevated NT-proBNP levels, and a history
diet – alongside pharmacological treatments including of recent HF hospitalizations or outpatient intravenous
diuretics, angiotensin-converting enzyme inhibitor diuretic use. These patients typically exhibit worsening
(ACEi), angiotensin II receptor blocker (ARBs), beta- symptoms despite being on maximally tolerated doses
blockers, and mineralocorticoid receptor antagonists of standard therapies, including ACE inhibitors, ARBs,
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(MRAs) In severe cases, surgical interventions such as beta-blockers, and MRAs. As such, vericiguat should be
implantable cardioverter-defibrillators (ICDs) or cardiac considered an adjunctive therapy for patients at high risk
resynchronization therapy (CRT) are considered. of adverse outcomes to reduce the likelihood of further
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Recent advancements in HFrEF management, such as hospitalizations and potentially improve survival, in line
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vericiguat, provide hope for improving outcomes in these with European and American HF management guidelines.
patients. Vericiguat is an oral soluble guanylate cyclase This review evaluates the efficacy of vericiguat and its
stimulator that enhances the activity of cyclic guanosine potential benefits for Pakistani patients with HFrEF.
monophosphate (cGMP), which plays a critical role in
regulating cardiovascular, renal, and metabolic functions. 2. Methodology
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The VICTORIA trial specifically targeted a higher- For this review, relevant articles were searched on electronic
risk population with HFrEF, characterized by elevated databases including PubMed, Science Direct, and Google
N-terminal pro-B-type natriuretic peptide (NT-proBNP) Scholar from 2013 to 2024 using keywords such as
levels, lower EFs, and recent hospitalizations for HF. The guidelines, HF, Pakistan, and reduced ejection fraction.
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trial demonstrated that vericiguat significantly reduced Inclusion criteria include article types such as cross-
the composite outcome of cardiovascular death or first HF sectional studies, narrative reviews, systematic reviews,
hospitalization in these patients (35.5% vs. 38.5%; hazard meta-analyses, and case reports that met the study’s
ratio, 0.90 [95% confidence interval, 0.82 – 0.98]), primarily objectives, written in the English language, conducted

Volume 8 Issue 2 (2025) 47 doi: 10.36922/itps.3756