Can Verquvo (Vericiguat) be used in patients with a left ventricular ejection fraction (LVEF) of 50%?

Vericiguat (Verquvo) Should Not Be Used in Patients with LVEF of 50%

Vericiguat (Verquvo) is not recommended for patients with a left ventricular ejection fraction (LVEF) of 50% as it is only indicated for patients with LVEF <45% who have had a recent heart failure decompensation event. 1

Evidence-Based Rationale

LVEF Criteria for Vericiguat Use

Vericiguat is specifically indicated for patients with:

• LVEF <45% (not 50% or higher)
• Symptomatic chronic heart failure (NYHA class II-IV)
• Recent heart failure hospitalization or need for outpatient IV diuretics
• Elevated natriuretic peptide levels 1

The VICTORIA trial, which established vericiguat's efficacy, exclusively enrolled patients with LVEF <45% who had experienced a recent worsening heart failure event 2. There is no evidence supporting its use in patients with LVEF of 50% or higher.

Heart Failure Classification Considerations

Patients with LVEF of 50% fall into the HFpEF (Heart Failure with preserved Ejection Fraction) category according to current guidelines:

• HFrEF: LVEF ≤40%
• HFmrEF: LVEF 41-49%
• HFpEF: LVEF ≥50% 1

Vericiguat's mechanism as a soluble guanylate cyclase (sGC) stimulator was specifically studied and approved for HFrEF patients, not for those with preserved ejection fraction 3.

Treatment Approach Based on LVEF

For Patients with LVEF ≥50% (HFpEF)

• Diuretics for symptom relief due to volume overload (Class I, Level C) 1
• Management of hypertension with beta-blockers, ACE inhibitors, or ARBs (Class IIa, Level C) 1
• Management of atrial fibrillation according to published guidelines (Class IIa, Level C) 1
• ARBs might be considered to decrease hospitalizations (Class IIb, Level B) 1

For Patients with LVEF <45% (Where Vericiguat Would Be Appropriate)

Vericiguat can be considered in addition to standard GDMT for patients who:

• Have LVEF <45%
• Are symptomatic (NYHA class II-IV)
• Have had a recent heart failure hospitalization within 6 months or received IV diuretics without hospitalization
• Have elevated natriuretic peptide levels 1, 3

Clinical Implications and Pitfalls

Important Considerations

• Using medications outside their evidence-based LVEF range may lead to harm or lack of benefit
• In HCM patients with LVEF ≥50%, cardiac myosin inhibitors (like mavacamten) should be discontinued if LVEF falls below 50% 1
• For patients with LVEF of 50%, focus should be on appropriate HFpEF therapies rather than medications indicated for reduced EF

Common Pitfalls to Avoid

1. Misclassification of heart failure type: Ensure accurate LVEF measurement and proper classification of heart failure type before selecting therapy
2. Inappropriate extrapolation of evidence: Don't assume medications effective in HFrEF will work similarly in HFpEF
3. Overlooking guideline-recommended therapies: For LVEF of 50%, focus on diuretics for symptom relief and management of comorbidities

Conclusion

Based on current guidelines and clinical evidence, vericiguat should be reserved for patients with LVEF <45% who have had a recent heart failure decompensation event. For patients with LVEF of 50%, other guideline-directed therapies specific to HFpEF should be utilized instead.