Vericiguat in Elderly Patients with Heart Failure and Reduced Ejection Fraction: Clinical Perspectives from Pathophysiology to Implementation.

Elderly patients with heart failure (HF) represent a rapidly growing and highly heterogeneous population marked by multimorbidity, frailty, and polypharmacy. These age-related features profoundly influence the course of HF and modify therapeutic response. Vericiguat, a novel oral soluble guanylate cyclase (sGC) stimulator, targets the impaired nitric oxide (NO)-sGC-cyclic guanosine monophosphate (cGMP) pathway, a central mechanism in vascular dysfunction and maladaptive remodelling. Clinical evidence, primarily from the VICTORIA trial and subsequent studies, supports vericiguat in selected patients with heart failure with reduced ejection fraction (HFrEF), particularly following recent worsening HF despite guideline-directed medical therapy (GDMT). Most of the available evidence derives from HFrEF populations, whereas studies in heart failure with preserved ejection fraction (HFpEF) have not demonstrated significant clinical benefit. In addition, dedicated evidence in frail older adults and in patients with geriatric syndromes remains limited. This review summarises current knowledge on the pharmacological rationale, pharmacokinetics, and pivotal clinical studies of vericiguat, highlighting quantitative results and their implications for clinical implementation in elderly patients with HFrEF and complex clinical profiles.