Vericiguat in Refractory HFrEF — EECC MCQ

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HardHeart FailureVericiguat in Refractory HFrEFEECC

A 68-year-old man with HFrEF (LVEF 28%) remains in NYHA class III despite maximally tolerated doses of sacubitril/valsartan, bisoprolol, eplerenone, and dapagliflozin. His eGFR is 35 mL/min/1.73 m² and potassium is 4.8 mmol/L. Which additional agent has demonstrated mortality benefit in this scenario?

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Correct answer: C — Vericiguat

Vericiguat is the correct add-on. It is an oral soluble guanylate cyclase stimulator used in symptomatic chronic HFrEF after optimisation of disease-modifying therapy; trial and guideline evidence supports reduction in cardiovascular death or heart-failure hospitalisation in patients with worsening symptomatic HFrEF despite ACEi/ARB/ARNI, beta-blocker and MRA therapy. This patient has severe HFrEF (LVEF 28%) and remains NYHA III despite ARNI, beta-blocker, MRA and SGLT2 inhibitor therapy; his eGFR 35 mL/min/1.73 m² is within the range in which vericiguat can be used, and potassium 4.8 mmol/L is not a contraindication. Digoxin may improve symptoms and reduce admissions but has no mortality benefit. Ivabradine is only for sinus rhythm with a persistently raised heart rate despite beta-blocker therapy and mainly reduces heart-failure hospitalisation. Hydralazine plus isosorbide dinitrate is reserved for ACEi/ARB intolerance or selected patients such as those of Black African/Caribbean family background with persistent symptoms. Omecamtiv mecarbil is not a standard UK-recommended mortality-reducing therapy.

Reference: Verquvo (vericiguat) Summary of Product Characteristics, electronic Medicines Compendium (UK), updated 2026: https://www.medicines.org.uk/emc/product/12774/smpc