5th and 6th pillars of

Heart Failure Management:

Kalyan Mitra, MD FRCP Edin MRCP (London) MRCPSG (Glasgow)

Despite recent advances in heart failure (HF) therapy, the risk of cardiovascular (CV) mortality, morbidity, and HF hospitalization (HFH) are major challenges in HF treatment.

Vericiguat and Finerenone are the two new weapons in our armamentarium for HF management in addition to the four known pillars of GDMT.

Vericiguat activates soluble guanylate cyclase (sGC) by binding to the beta-subunit, bypassing the requirement for NO-induced activation. The nitric oxide (NO)–sGC–cyclic guanosine monophosphate (cGMP) pathway plays an essential role in cardiovascular (CV) regulation and the protection of healthy cardiac function but is impaired in HF. Vericiguat reduced the risk of CV death and HFH in HF patients with reduced ejection fraction (HFrEF) but showed no therapeutic effect on HF with preserved ejection fraction (HFpEF). The trials demonstrated a favourable safety profile with most common adverse events such as hypotension, syncope, and anaemia. Therefore, vericiguat is recommended for patients with HFrEF and a minimum systolic blood pressure of 100 mmHg. Treatment with vericiguat is considered when the individual patient experiences decompensation despite being on guideline-recommended medication, e.g., ACE inhibitor/ARB, beta-blockers, spironolactone, and SGLT2 inhibitors. Furthermore, larger studies are required to investigate any potential effect of vericiguat in HFpEF patients. Despite the limitations, vericiguat can be recommended for patients with HFrEF, where standard-of-care is insufficient, and the disease worsens.

Finerenone a non-steroidal MRA ,which has already shown to lower risk of CKD progression and CV events in DM patients with CKD was evaluated recently in the FINEARTS HF trial for HF. In patients with heart failure and mildly reduced or preserved ejection fraction, Finerenone resulted in a significantly lower rate of a composite of total worsening heart failure events and death from cardiovascular causes than placebo and was associated with better patient-reported health status as well as an increased risk of hyperkaliemia but a decreased risk of hypokalemia.

Message to the society:

Acute heart failure (sudden inability of the heart to pump properly) is associated with an often underrecognized, but significant death toll in our society. As our society ages its incidence is rising. In hospital death rate ranges from 2% to 5%. Post discharge death rates approach 10% at 90 day follow up and 30% at 1 year.

Even higher than a lot of CANCERS.

Nearly 25% of patients are readmitted within 30 days of discharge, and 50% are readmitted within 6 months.

Each subsequent hospitalisation following the first stay is associated with increasing risk of death. We need to recognize and treat this condition using proper medical guidelines to reduce death in our aging population. However, issues related to the accessibility and affordability of these medications persist in our society and require appropriate attention from the relevant authorities.