Page 57 - ITPS-8-2

INNOSC Theranostics and
Pharmacological Sciences Management of heart failure in Pakistan

the additive benefit of the drug itself. To better assess countries like Pakistan is less well-understood. A study
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the efficacy of new drugs, future studies should ensure showed that the clinical assessment of CHF symptoms, as
that all participants are on full GDMT before introducing determined by the NYHA classification, did not accurately
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additional therapies. 18 reflect the severity of the disease. It was also found that
many CHF patients with reduced ejection fraction were
3.5.3. Subgroup differences between quartiles not being prescribed the appropriate medications, such
The presence of notable differences between quartiles as ACE inhibitors and beta blockers, as recommended
(e.g., Q1 – Q3 vs. Q4) in terms of baseline characteristics by clinical guidelines. This indicates a need for improved
and outcomes suggests potential biases in the study design assessment and treatment of CHF in Pakistan. 20
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that may limit its ability to deliver robust conclusions about
the general HFrEF population. For example, if patients 3.7. Consideration when administering or using
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medications for HFrEF
in Q4 had higher baseline NT-proBNP levels or worse
kidney function compared to those in Q1 – Q3, the overall There are a few considerations when using the above
outcomes could be skewed by these more severe cases, medications to treat HFrEF; the patient’s other health
making the treatment appear less effective than it might be conditions and risk factors should be considered before
in a more homogenous population. 7 administering the drugs. For example, if a patient has
diabetes or kidney problems, some of these medications
This variability highlights the need for more precise 21
stratification in the study design to ensure comparability may not be suitable for them. Another consideration is the
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across different patient subgroups. The post hoc analysis patient’s age and overall health. Beta-blockers, for example,
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by Senni et al. emphasizes that subgroup analysis is critical may not be suitable for elderly patients or those with a
history of heart block or asthma. It is also important to
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in interpreting clinical trial results for HF treatments. consider whether the patient is pregnant or breastfeeding,
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Their findings suggest that patients with high-risk profiles as some of these medications can be harmful to the
or more advanced disease stages may not benefit as much fetus or baby. Table 3 presents potential challenges and
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from certain therapies, which could explain the differences
observed between quartiles in the current study. Thus, considerations for vericiguat implementation in Pakistan.
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while the study provides valuable insights on the use of 3.8. Current guidelines of vericiguat and its
vericiguat, its design limits the applicability of its findings implications in Pakistan
to the broader HFrEF population, necessitating further
research with more homogeneous patient groups. In patients with HFrEF, vericiguat, a new oral sGC
activator, has demonstrated promise in lowering the risk
3.6. Challenges faced in the treatment of HFrEF of cardiovascular death and HF hospitalizations. 22,23 For
instance, vericiguat stimulates the biochemical pathways
Studies have shown that patients with HFrEF in Pakistan of cGMP and NO, which are impaired in patients with
are not receiving the optimal medication dosages, resulting HF. Therefore, patients with HFrEF who are experiencing
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in suboptimal treatment outcomes. This is likely due to symptoms even after receiving the best medical care and
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a variety of factors, including a lack of awareness about whose HF is worsening may consider vericiguat as a new
optimal dosages, a lack of access to medications, and poor treatment option. Patients with HFrEF who fit specific criteria
adherence to the treatment regimen. The main challenges might consider receiving vericiguat medication. Based on
faced in the treatment of HFrEF are poor adherence to the guidelines and trial conditions, the eligibility to receive
the treatment plan and side effects from the medications. vericiguat varies; about 21.4% of patients with HFrEF would
Adherence can be a challenge because some of the be eligible for vericiguat treatment based on the VICTORIA
medications need to be taken multiple times a day and trial’s criteria. The most significant factors influencing
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must be continued for life. Side effects of the medications this eligibility include the usage of nitrates, increased
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can include dizziness, fatigue, cough, and headaches. Some NT-proBNP levels, and recent hospitalization for HF. The
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people may also experience low blood pressure and kidney VICTORIA study, a prospective, randomized, double-blind,
problems. Another challenge can be the cost, as some HF placebo-controlled study, evaluated the efficacy and safety
medications are expensive. of vericiguat in patients with HF. The study found that
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Depression is a common comorbidity in patients vericiguat supplementation, at a target dose of 10 mg twice
with CHF in general, and it is associated with increased a day, reduced cardiovascular death and hospitalization for
morbidity and mortality. While this has been studied HF in patients with clinical manifestations of chronic HF
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in high-income countries, the prevalence and impact of and reduced ejection fraction. In Pakistan, the introduction
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depression in CHF patients in low- and middle-income of vericiguat may have an impact on the management of

Volume 8 Issue 2 (2025) 51 doi: 10.36922/itps.3756