Vericiguat in advanced heart failure patients receiving chronic intermittent levosimendan infusions: a prospective pilot study

Background Although treatment options for heart failure (HF) have improved, advanced HF (AdHF) remains a challenging condition, impacting over 10% of patients with a poor prognosis. In severe cases, patients may experience resistance to or intolerance of conventional therapies, leading to frequent hospitalisations and a heightened risk of death. Vericiguat, a novel treatment for HF with reduced ejection fraction (HFrEF), has shown promise in improving outcomes for patients with worsening HF. The VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction) trial demonstrated that vericiguat can reduce the risk of adverse events in patients with EF<45% following a worsening HF event. However, its safety and efficacy in AdHF patients previously receiving chronic levosimendan infusions remain unclear. Methods and results In this prospective study, we evaluated the safety and tolerability of vericiguat in AdHF patients treated with monthly levosimendan infusions at our clinic. Among 18 patients, 8 were eligible for vericiguat, which was associated with better echocardiographic findings, improved quality of life and lower 1-year mortality compared with non-eligible patients. However, 37.5% of patients discontinued the drug due to symptomatic hypotension, highlighting a key challenge in managing this fragile population. Despite this, vericiguat was generally well-tolerated, and no severe adverse effects were observed. Discussion This study provides the first prospective evidence supporting the safe use of vericiguat in AdHF patients on chronic levosimendan. However, careful monitoring for hypotension is essential, and titration may be more difficult in this population. Further research is needed to optimise treatment strategies for these high-risk patients.