Sildenafil in HFpEF (Heart Failure With Preserved Ejection Fraction) and PH
Sildenafil in HFpEF (Heart Failure With Preserved Ejection Fraction) and PH
Aim of the study is to investigate whether Sildenafil treatment results in a reduction of
 pulmonary artery pressure without decrease of cardiac output (CO) and in improvement of
 exercise capacity in patients with heart failure with preserved ejection fraction (HFpEF)
 with pulmonary hypertension ( PH).
Rationale: Treatment of diastolic left heart failure is a challenging task. Compared to
 systolic left heart failure the level of evidence for known medical treatment regiments is
 low. Sildenafil, a phosphodiesterase 5 (PDE 5) inhibitor and effective therapy for pulmonary
 arterial hypertension acts as a selective pulmonary vasodilator by inhibiting the impaired
 nitric oxide (NO) pathway. Reducing the pulmonary vascular resistance would be the primary
 target by treatment of diastolic left heart failure with PH. But clinical and hemodynamical
 studies to evaluate the role of Sildenafil in diastolic heart failure, also called heart
 failure with preserved ejection fraction (HFpEF) with secondary pulmonary hypertension are
 lacking. Our hypothesis is that Sildenafil decreases pulmonary artery pressure in patients
 with HFpEF and pulmonary hypertension.

 Objective: To investigate whether Sildenafil treatment results in a hemodynamic improvement
 and in an improvement of exercise capacity in these patients.

 Study design: single-center, prospective, randomized, placebo controlled study. Study
 population: 52 patients with HFpEF and PH Intervention : One group receives three times daily
 20 mg Sildenafil for 2 weeks followed by three times daily 60 mg Sildenafil for 10 weeks. The
 other group receives three times daily 20 mg of Placebo, followed by 3 times daily 60 mg
 placebo.

 Main study parameters/endpoints:

 Primary objectives

 1. To investigate whether Sildenafil treatment results in a reduction of pulmonary artery
 pressure (PAP) in HFpEF patients with PH (investigated invasively by right heart
 catheterization) .

 Secondary objectives

 1. To investigate whether Sildenafil treatment results in an reduction of wedge pressure in
 HFpEF patients.

 2. To investigate whether Sildenafil treatment results in an improvenemt of cardiac output
 (CO) in HFpEF patients.

 3. To investigate whether Sildenafil treatment results in improvement of exercise capacity
 in these patients ( defined as change in VO2max)
Inclusion Criteria:

 -  >18 years

 -  Written inform consent

 -  PH secondary to diastolic left heart failure defined as

 -  PAP mean >25 mmHg

 -  Wedge mean >15 mmHg

 -  Normal systolic left ventricular (LV) function on echo/nuclear imaging (left
 ventricular ejection fraction (LVEF) > or =45%)

 -  New York Heart Association class (NYHA) II-IV despite heart failure therapy

 Exclusion Criteria:

 -  Severe noncardiac limitation to exercise (as severe chronic obstructive pulmonary
 disease)

 -  Other cause of PH besides diastolic heart failure

 -  Coronary ischemia or recent myocardial infarction (<6 months)

 -  Hypotension ( <90/50 mmHg)

 -  Ongoing nitrate therapy

 -  Ongoing therapy with citochrome P450 3A4 ( CYP3A4) inhibitors (ketoconazole,
 erythromycin, cimetidine, clarithromycin, itraconazole, voriconazole and protease
 inhibitors) or CYP3A4 inductors(carbamacepine, phenytoin, phenobarbital, rifampicin,
 Sint Janskruid ). Furthermore patients will be informed not to drink grapefruit juice
 while on study medication because of the known impact of grape fruit on
 pharmacokinetics of Sildenafil.

 -  Ongoing therapy with alpha -inhibitors

 -  Significant mitral or aortic valve dysfunction

 -  Severe liver dysfunction

 -  Pregnancy

 -  Unable to read and comprehend Dutch language