Table 9.1. Guanylate cyclase stimulators for the treatment of HFrEF patients.

Notes	Comment	Table 2018	Ref.
Vericiguat in patients with LVEF lower than 45%, NYHA II – IV to reduce morbidity, especially in patients with frequent hospitalizations despite optimized guideline-directed medical therapy.	POTENTIAL: The observations described herein reflect data from recent studies on this new class of drug. However, it has not been approved by Anvisa for use in Brazil yet.	New	126, 127
Vericiguat acts by supplying the relative deficit of cyclic GMP production in HF patients126 and was assessed in a multicenter, randomized, double-blind, placebo-controlled trial with HFrEF patients, the VICTORIA (Vericiguat in Patients with Heart Failure and Reduced Ejection Fraction) trial. In the Victoria, 5050 patients with HFrEF, with LVEF lower than 45%, NYHA II-IV, were randomized to receive vericiguat 10 mg/day orally or placebo, in addition to guideline-directed medical therapy. The primary endpoint was cardiovascular death or first hospitalization for HF. In an 11-month period, the primary endpoint occurred in 35.5% of the vericiguat group and 38.5% of the placebo group, which represents a number needed to treat (NNT) of 24 to save one life over 11 months. The benefit of the composite outcome was primarily attributed to the reduction in hospitalization rates, with no statistically significant impact on cardiovascular or overall mortality.127 The drug could potentially join the set of medications acting on symptoms and readmissions for HFrEF patients, representing an additional option: for patients who undergo frequent hospitalizations despite optimized therapy; who have impaired kidney function, since patients eligible for the trial had GFR above 15%; or who are intolerance to other medications. It should be stressed that this medication class is contraindicated in combination with nitrates.

GFR: glomerular filtration rate; HF: heart failure; HFrEF: heart failure with reduced ejection fraction; LVEF: left ventricular ejection fraction; NYHA: New York Heart Association.