Efficacy and safety of vericiguat in patients with HFrEF treated with sacubitril/valsartan: results from the VICTORIA trial

Background

In the VICTORIA trial (n=5050) the reduction in the primary composite endpoint of cardiovascular death (CVD) or heart failure hospitalization (HFH) was similar whether or not patients received sacubitril/valsartan. The distribution of those patients who received sacubitril/valsartan after randomization (drop-ins) and the relationship to the efficacy and safety of vericiguat is unknown.

Purpose

We assessed the efficacy and safety of vericiguat in patients who were or were not treated with sacubitril/valsartan at baseline in the VICTORIA trial and the implications of post- randomization use of sacubitril/valsartan.

Methods

A total of 5040 patients were analyzed according sacubitril/valsartan use at randomization or initiated after randomization. The efficacy of vericiguat on the primary composite endpoint and its components, time to first HF hospitalization or all-cause mortality, were assessed according to sacubitril/valsartan use. Safety outcomes included symptomatic hypotension, syncope, worsening renal function, and hyperkalemia.

Results

Overall, 731 patients (360 on vericiguat and 371 on placebo) received sacubitril/valsartan at randomization. Patients treated with sacubitril/valsartan were twice as likely to be from Western Europe or North America, to have a lower ejection fraction and systolic and diastolic blood pressures, were more often on triple therapy (65.9 vs 58.6%), and more likely to have received biventricular pacing (17.9 vs 14.1%) or ICDs (42.3 vs 25.3%). For patients on sacubitril/valsartan at baseline, the adjusted hazard ratios for vericiguat's treatment effect on the primary composite outcome, CVD, and HFH was 0.94 (95% CI 0.74–1.20), 0.81 (95% CI 0.55–1.20) and 0.99 (95% CI 0.76–1.30), respectively. For those patients not on sacubitril/valsartan (2161 vericiguat; 2148 on placebo), the corresponding adjusted hazard ratios for vericiguat's treatment effect on the primary composite outcome, CVD, and HFH were 0.89 (0.80–0.98), 0.95 (0.82–1.11), and 0,87 (0.78–0.98), respectively. There was no significant interaction on the treatment effect of vericiguat based on the use of sacubitril/valsartan. More placebo patients (n=238) received drop-in use of sacubitril/valsartan than vericiguat group (n=187; p=0.007) post-randomization during follow-up (Figure). Overall, adverse events in the 992 patients receiving sacubitril/valsartan (at either baseline or drop-in for at least 3 months) were not significantly different according to those on placebo vs vericiguat for symptomatic hypotension (21.0% vs 23.1), renal dysfunction (8.0 vs 9.0%), and hyperkalemia (10.3 vs 7.9%).

Conclusions

Sacubitril/valsartan use was initiated more frequently after randomization in patients on placebo than on vericiguat. Concomitant use of sacubitril/valsartan did not alter the efficacy of vericiguat and was similarly tolerated in both study arms.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Merck & Co., Inc. and Bayer

Hemoglobin, anemia, and clinical outcomes in vericiguat global study in subjects with heart failure with reduced ejection fraction (VICTORIA)

Background

In the VICTORIA trial of patients with HFrEF after a worsening HF event, anemia occurred more often in patients treated with vericiguat (7.6%) compared with placebo (5.7%). We explored the association between vericiguat, baseline hemoglobin, and anemia and also whether hemoglobin was related to the benefit of vericiguat in HF.

Methods

Anemia was defined as a hemoglobin <13.0 g/dL in men and <12.0 g/dL in women (WHO anemia). Adverse events reported as new anemia were also evaluated (AE anemia). We evaluated the risk-adjusted relationship between baseline hemoglobin (as both quartiles and continuous variable), hematocrit, and hematinic indices with the primary outcome (composite of cardiovascular death or heart failure hospitalization). Time-updated hemoglobin relationship was also examined.

Results

Of 4812 patients with baseline hemoglobin data available, 1719 (35.7%) were WHO anemic; median hemoglobin was 13.4 g/dL (IQR 12.1 to 14.7 g/dL). In total, 1643 patients had WHO anemia at 16 weeks (of which 284 were new from baseline for vericiguat and 219 for placebo) and this occurred more often in the vericiguat group than the placebo group (P<.001). Subsequently, there was no further decline in hemoglobin over the 96 weeks of follow-up (Figure A). The ratio of hemoglobin/hematocrit remained constant and none of the hematinic indices including red cell density width, mean corpuscular volume, white blood cell or platelet counts changed over time. Overall, AE anemia occurred in 342 patients (7.1%) and was more frequent in those with a lower baseline hemoglobin (hemoglobin Q1: 184 [14.5%], Q2: 94 [7.9%], Q3: 40 [3.4%], Q4: 24 [2.1%]; p<.001). Whereas outcomes were associated, quartiles of baseline hemoglobin were not related to the treatment benefit of vericiguat (compared with placebo) for the primary outcome (Figure B). Additionally, analysis of the time-updated hemoglobin values revealed no association with the treatment effect of vericiguat (compared with placebo) on the primary outcome.

Conclusions

Anemia was present at baseline in over one-third of patients in the VICTORIA trial and was generally mild. Lower hemoglobin was associated with greater frequency of clinical events. Although vericiguat modestly lowered hemoglobin by 16 weeks, this effect did not further progress nor influence the association of benefit of vericiguat.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Merck & Co., Inc. and Bayer