Page 55 - ITPS-8-2

INNOSC Theranostics and
Pharmacological Sciences Management of heart failure in Pakistan

vericiguat is 2.5 mg, taken orally once daily with food; this experiencing worsening heart failure events. This
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dose should be increased approximately every 2 weeks population includes those with a history of decompensation
until it reaches the target maintenance dose of 10 mg once events leading to emergency department visits and
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daily, as tolerated by the patient. African Americans were hospitalizations. The focus is on optimizing treatment
significantly underrepresented in the VICTORIA trial, for high-risk patients, particularly those who have not
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accounting for only 4.9% of the vericiguat arm and 5% responded adequately to standard therapies. In Pakistan,
of the placebo arm. However, this underrepresentation HF is a major public health issue, and further research is
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should be considered in the context of the trial’s global needed to explore the use and role of vericiguat in patients
nature, with the majority of trial sites located in Eastern with HFrEF.
Europe and the Asia Pacific region – have low populations 3.4. Safety profile of vericiguat and its adverse
of the African diaspora. It is worth noting that other effects
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recent positive HF trials, such as PARADIGM-HF
and DAPA-HF, also had low representation of African A study has shown that vericiguat has proven effective in
Americans, with percentages ranging between 4.4% and reducing cardiovascular mortality and hospitalization rates
5.1%. Table 2 shows the eligibility criteria for inclusion of for HF patients with reduced ejection fraction (HFrEF),
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HFrEF patients in vericiguat clinical trials. but did not demonstrate a therapeutic benefit for those
with preserved ejection fraction (HFpEF). The treatment
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At present, clinical trial data on vericiguat in Pakistan showed a favorable safety profile, with common adverse
are scarce, raising concerns given the increasing prevalence events including hypotension, syncope, and anemia.
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of cardiovascular diseases in the country. Conducting a Consequently, vericiguat is indicated for HFrEF patients
clinical trial of vericiguat in Pakistan would be a significant with a minimum systolic blood pressure of 100 mmHg,
step forward in addressing the management of HFrEF particularly those experiencing symptom worsening
among the Pakistani population. Such a trial would not despite optimal medical therapy, including ACE inhibitors,
only benefit the local population but also contribute beta-blockers, spironolactone, and SGLT2 inhibitors. 16
to enhancing global HF care. Figure 1 shows the role of
vericiguat in HFrEF. Another study found that vericiguat significantly
lowered the risk of cardiovascular death or hospitalization
3.3. Potential benefits of vericiguat for HF due to HF in high-risk patients, showcasing its positive
management in Pakistan impact on clinical outcomes. 16
Among FDA-approved medications between 2021 and 3.5. Flaws and limitations of VICTORIA’S trial
2022, vericiguat was notable, with the most commonly
reported side effects of hypotension and anemia – both The VICTORIA trial demonstrated that vericiguat
exceeding 5% of reported incidents. Using sacubitril/ significantly reduced the risk of cardiovascular death and
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valsartan in the Pakistani population with HFrEF is hospitalization for heart failure compared to placebo,
generally safe and well-tolerated, as indicated by stable with a hazard ratio of 0.90 for the primary composite
hemodynamic parameters and a notable improvement in outcome (Table 1). Hospitalization rates were slightly
lower in the Vericiguat group (35.5%) versus placebo
left ventricular function and functional class. Thus, this (38.5%), indicating a modest benefit (Table 1). However,
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therapy can be considered as a primary treatment option this marginal reduction may reflect suboptimal baseline
for patients with HFrEF, with a gradual dose escalation therapy among participants, suggesting Vericiguat’s full
over a 6-week timeframe. 15
potential could be greater under optimized conditions.
The benefit of vericiguat in heart failure with reduced While generally well-tolerated, Vericiguat was associated
ejection fraction (HFrEF) was studied in patients with a higher incidence of new anemia (Table 1). The

Table 2. Eligibility criteria for inclusion of heart failure with reduced ejection fraction patients in vericiguat clinical trials
Eligibility Criteria Description Reference (s)
Symptoms despite optimal medical care HFrEF patients experiencing symptoms despite receiving optimal medical care. 12-14
Worsening heart failure HFrEF patients with worsening condition despite receiving treatment. 12-14
Usage of nitrates HF patients using nitrates. 12-14
Increased NT-proBNP levels Patients with elevated levels of N-terminal pro-B-type natriuretic peptide 12-14
(NT-proBNP), indicating HF severity. 12-14
Abbreviations: HF: Heart failure; HFrEF: Heart failure with reduced ejection fraction; NT-proBNP: N-terminal pro-B-type natriuretic peptide.

Volume 8 Issue 2 (2025) 49 doi: 10.36922/itps.3756