Vericiguat, organic nitrates, and heart failure in African Americans

African Americans (AA) have a higher prevalence of heart failure (HF) when compared with White Americans (3% vs 2%), respectively and HF comes on at an earlier age and is more severe in AA. The A-HEFT trial with the combination of hydralazine and isosorbide dinitrate (ISDNHYD) for self-described AA with NYHA class III–IV heart failure with reduced ejection fraction (HFrEF) showed reduction in mortality and HF hospitalizations with a class I level of evidence A recommendation in the ACC/AHA guidelines. Vericiguat is an oral soluble guanylate cyclase stimulator that enhances the cyclic guanosine monophosphate (GMP) pathway. A randomized, double-blind, placebo-controlled trial in patients with higher risk HFrEF in which AA were underrepresented found that vericiguat reduced the composite primary outcome of cardiovascular death or first HF hospitalization. In the new era of guideline directed medical therapies of quadruple therapy – hydralazine and isosorbide dinitrate should be preferred over vericiguat in AA with HFrEF. •In African Americans with heart failure with reduced ejection fraction (HFrEF) on quadruple guideline directed medical therapy with (ACEI/ARNI/ARB, beta blocker, spironolactone andSGLT2 inhibitor, the combination of hydralazine and isosorbide dinitrate should be preferred over vericiguat.