Newer and Developing Therapies for Treating HFrEF

James Januzzi, MD: We're drawing close to the end, and I want to give a rapid-fire question to each of you, 1 drug, 1 minute for each. These are some of the newer therapies or somewhat lesser-used therapies, but with an important role when we manage our patients. Nasrien, let me ask you about the role of Ivabradine. When do you use it? When is it a value?

Nasrien E. Ibrahim, MD: It's a value only in patients that have been on maximum tolerated or target doses of beta-blockers that still have an elevated heart rate above 70. I have rarely used it, and when I've used it, it's been really well tolerated. You really need to push the beta-blockers to max dose before considering Ivabradine.

James Januzzi, MD: Very important message. Max your beta-blocker, but there is a reverse remodeling effect. If you have maxed it out and you add Ivabradine, it improves quality of life and exercise tolerance worthwhile only in people in sinus rhythm. However, Gregg, omecamtiv mecarbil, can you give us a sense of the recent results for omecamtiv and where you see it might fit in?

Gregg C. Fonarow, MD: Yes. Calcium sensitizer, calcitrope—it was studied in patients with the ejection fractions [EFs] 35% or below on standard background therapy. Overall, a modest effect in GALACTIC-HF of about 8% reduction in CV [cardiovascular] death or heart failure hospitalization. But importantly, subgroup analysis had shown particularly for those patients with left ventricular ejection fraction [LVEF] of 25% or below larger impact. Not yet FDA approved, but I think it will have an important role for those patients who can't tolerate some of these other therapies; have persistently low ejection fraction and may help us with these patients as a bridge to additional medications, as well as reducing their risks. It's going to be for a narrow population should it become FDA approved and particularly defined by those with more severe heart failure symptoms and those with the EFs 25% or below.

James Januzzi, MD: Yes, that's great. For us who see these patients who are intolerant of other therapies, this is a very important potential application. Javed, the last one. If you can give us in a minute the role of vericiguat as you see it, which is approved for use now.

Javed Butler, MD: Yes. Novel mechanism of action soluble guanylate cyclase stimulator. This is a ubiquitous target around the body. We know that in oxidative stress that is common in patients with heart failure. Vericiguat is given to patients with worsening heart failure. These are the patients who were hospitalized within the past 6 months or required IV diuretics, or an urgent outpatient visit within the past 3 months. They really targeted high-risk patients, 10% relative risk reduction in cardiovascular death, heart failure hospitalization, about 4.2% absolute risk reduction because these are really high-risk patients. Currently, I’d say that therapy should be given to people who are developing worsening signs and symptoms either on the stable foundational therapy or are unable to tolerate foundational medical therapy and are getting into trouble. Having said that, the mechanism of action is such that there are all the reasons to believe that if this drug were to be given earlier in the disease process before worsening heart failure, then you can prevent a development of worsening heart failure in the first place. But that question has to be studied.

James Januzzi, MD: Great.

This transcript has been edited for clarity.