We report a case of an elderly woman with heart failure with preserved ejection fraction and pulmonary hypertension (HFpEF-PH), refractory to conventional therapy for left heart failure and successfully treated by sildenafil

Antonio Totaro

Armando Ferraretti

Matteo Di Biase

Michele Correale

Natale Daniele Brunetti

Monaldi Archives for Chest Disease

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Monaldi Arch Chest Dis2013; 80: 193-194 CASE REPORTCaseA seventy-two years old woman, with arterialhypertension, diabetes mellitus, permanent atrialfibrillation and previous mitral commisuroplasty forrheumatic mitral stenosis, was admitted to our De-partment, after a new decompensated heart failure(WHO functional class III-IV). An echocardiographic examination showed di-lated right chambers, left ventricle with D-shapedconfiguration, moderate mitral stenosis (mean PG: 9mmHg), moderate aortic regurgitation, severe tri-cuspid regurgitation and the continuous-waveDoppler showed a peak velocity consistent with apressure gradient of 95 mmHg and a pulmonary ar-terial systolic pressure (PAsP) of 115 mmHg.Right heart catheterization showed a high mean pul-monary arterial pressure (mPAP 80mmHg) and highpulmonary arterial wedge pressure (PWP 30mmHg)with transpulmonary gradient (TPG) >12 mmHg(mean PAP - mean PWP: 50 mmHg). She performedthe six minutes walking test and walked 230 meters(53% of predicted value).In ambulatory setting, the therapy for left heartfailure was most titrated; however, she remained inWHO functional class III and she refused cardiacsurgery evaluation. So, we started therapy with silde-nafil 10 mg die (with slow titration up to 60 mg die).After one month of sildenafil therapy, she began toimprove functional and clinical status (260 m at the6MWT and WHO functional class II-III) with a re-duction of the PAsP (95 mmHg). After four monthsof therapy, she received up to sildenafil 60 mg dieand further functional status improved (WHO func-tional class II). After 6 months no major events (hos-pitalization, cardiac death, death) was observed. DiscussionPulmonary hypertension with elevated TPG oc-curs in patients with mitral stenosis, and is signifi-cantly more common in females [1].Most of the advances in the treatment of PH havebeen made in PAH, while a few progress has beenmade for the PH due to left heart diseases. Despitethe lack of data, drugs with proven efficacy in PAHare increasingly being used for other forms of PH.Recent studies suggest the usefulness of sildenafil,a phosphodiesterase-5 inhibitor in particular sub-groups. In fact, sildenafil appears to be well toleratedand can improve markers of cardiovascular and pul-monary function in patients with HF. So, the PDE5 in-hibitors may be a therapeutic option for patients whocannot tolerate standard therapy for HF or who remainsymptomatic with standard therapy, as in this case [2].Sildenafil improves exercise capacity and qual-ity of life in patients with systolic HF with sec-ondary PH [3] and improves left ventricular dias-tolic function, cardiac geometry, and clinical statusin patients with stable systolic heart failure [4].Sildenafil improves clinical and functionalstatus of an elderly postmenopausal femalewith ‘out of proportion’ PH associated with left heart diseaseTerapia con Sildenafil migliora clinica e stato funzionale di una anziana donna con ipertensione polmonare associata a patologia del cuore sinistroMichele Correale, Antonio Totaro, Armando Ferraretti, Matteo Di Biase, Natale Daniele BrunettiDepartment of Cardiology, University of Foggia, Foggia, Italy.Corresponding author: Michele Correale, Department of Cardiology; “Ospedali Riuniti”OO.RR; viale L Pinto, 1; I-71100 Foggia,Italy; Tel 0881733652; Fax 0881745424; E-mail address: opsfco@tin.itABSTRACT: Sildenafil improves clinical and functional statusof an elderly postmenopausal female with ‘out of proportion’PH associated with left heart disease. M. Correale, A. Totaro,A. Ferraretti, M. Di Biase, N. Daniele Brunetti.We report a case of an elderly woman with heart fail-ure with preserved ejection fraction and pulmonary hyper-tension (HFpEF-PH), refractory to conventional therapy forleft heart failure and successfully treated by sildenafil.Keywords: sildenafil, pulmonary hypertension, left heartfailure, diastolic heart failure.Monaldi Arch Chest Dis 2013; 80: 193-194.However, contrast data come from subgroupwith HFpEF. In fact, in a multicenter, double-blind,placebo-controlled, parallel-group, randomized clin-ical trial with 216 stable outpatients with HFpEF, theauthors showed administration of sildenafil for 24weeks, compared with placebo, did not result insignificant improvement in exercise capacity orclinical status [5].Instead, we report a case of an elderly post-menopausal female with residual mitral stenosispost-commissurotomy and permanent atrial fibril-lation, where the therapy for left heart failure wasmost titrated, but, she remained in WHO functionalclass III. So, sildenafil therapy was performed andshe began to improve functional and clinical statuswith a reduction of the PAsPs. After four months oftherapy, she received up to sildenafil 60 mg die andfurther functional status improved (WHO func-tional class II). Over the last decade there has been growing in-terest in using phosphodiesterase-5 (PDE-5) in-hibitors in HF associated with group 2 pulmonaryhypertension (PH), with benefits reported on pul-monary haemodynamic and functional status onlyin a single-centre trials [3], however our data seemto confirm it. Further studies to assess sildenafil efficacy andtolerability in patients with HF and evidence ofgroup 2 PH are necessary, so recently, a randomized,placebo-controlled multinational trial designed toassess this aim in patients with HF (WHO functionalclass II or III) and evidence of group 2 PH was de-signed and we looking forward the results [6].RiassuntoRiportiamo il caso di una donna anziana conscompenso cardiaco a preservata frazione d’eie-zione ed ipertensione polmonare, refrattario allaterapia convenzionale per lo scompenso cardiacosinistro e trattato con successo con sildenafil.References1. Hart SA, Krasuski RA, Wang A, Kisslo K, HarrisonJK, Bashore TM. Pulmonary hypertension and elevatedtranspulmonary gradient in patients with mitral stenosis. JHeart Valve Dis 2010 Nov; 19(6): 708-15.2. Cvelich RG, Roberts SC, Brown JN. Phosphodiesterasetype 5 inhibitors as adjunctive therapy in the managementof systolic heart failure. Ann Pharmacother 2011 Dec;45(12): 1551-8. 3. Lewis GD, Shah R, Shahzad K, Camuso JM, Pappa-gianopoulos PP, Hung J, Tawakol A, Gerszten RE, Sys-trom DM, Bloch KD, Semigran MJ. Sildenafil improvesexercise capacity and quality of life in patients with sys-tolic heart failure and secondary pulmonary hypertension.Circulation 2007 Oct 2; 116(14): 1555-62. 4. Guazzi M, Vicenzi M, Arena R, Guazzi MD. PDE5 inhi-bition with sildenafil improves left ventricular diastolicfunction, cardiac geometry, and clinical status in patientswith stable systolic heart failure: results of a 1-year,prospective, randomized, placebo-controlled study. CircHeart Fail 2011 Jan; 4(1): 8-17. 5. Redfield MM, Chen HH, Borlaug BA, Semigran MJ, LeeKL, Lewis G, LeWinter MM, Rouleau JL, BullDA, Mann DL, Deswal A, Stevenson LW, GivertzMM, Ofili EO, O’Connor CM, Felker GM, GoldsmithSR, Bart BA, McNulty SE, Ibarra JC, Lin G, Oh JK, Pa-tel MR, Kim RJ, Tracy RP, Velazquez EJ, AnstromKJ, Hernandez AF, Mascette AM, Braunwald E; RELAXTrial. Effect of phosphodiesterase-5 inhibition on exer-cise capacity and clinical status in heart failure withpreserved ejection fraction: a randomized clinical trial.JAMA 2013 Mar 27; 309(12): 1268-77.6. Cooper TJ, Guazzi M, Al-Mohammad A, Amir O, BengalT, Cleland JG, Dickstein K. Sildenafil in Heart failure(SilHF). An investigator-initiated multinational random-ized controlled clinical trial: rationale and design. Eur JHeart Fail 2013 Jan; 15(1): 119-22.194M. CORREALE ET AL.

Sildenafil improves clinical and functional status of an elderly postmenopausal female with ‘out of proportion’ PH associated with left heart disease

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Sildenafil improves clinical and functional status of an elderly postmenopausal female with ‘out of proportion’ PH associated with left heart disease

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