{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,4]],"date-time":"2025-11-04T11:34:35Z","timestamp":1762256075983,"version":"build-2065373602"},"reference-count":46,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2025,11,3]],"date-time":"2025-11-03T00:00:00Z","timestamp":1762128000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pharmaceuticals"],"abstract":"<jats:p>Background: Heart failure (HF) with pulmonary hypertension due to left-sided heart disease (PH-LHD) is associated with poor prognosis. Dapagliflozin showed benefits in terms of ejection fraction (EF); meanwhile, sildenafil improved pulmonary pressures and right ventricular function in PH -LHD in recent clinical studies. This study assesses the potential additive effects of dapagliflozin and sildenafil on cardiac function and pulmonary hemodynamics in this population. Methods: In this prospective, randomized, controlled trial, 93 participating patients with HF and PH-LHD were randomly assigned to receive dapagliflozin (control group, n = 48) or dapagliflozin plus sildenafil 25 mg\/day (test group, n = 45) in addition to conventional therapy for HF for 12 weeks. The primary outcomes were assessing changes in echocardiographic hemodynamic parameters. Secondary outcomes included outcomes, changes in cardiac enzyme (troponin), kidney function (serum creatinine), and lipid profile. Results: The average baseline median left ventricular ejection fraction (LVEF) for both groups was 30%, and the Pulmonary Artery Systolic Pressure (PASP) median was 50 mmHg. At follow-up, PASP had declined, and EF had improved compared to baseline. However, there were no statistically noticeable variations between the groups (p = 0.458, 0.331, respectively). No notable changes were observed in secondary and safety outcomes, including hospitalization rate, number of deaths, kidney function, and cardiac enzymes (p = 0.524, 1, 0.923, and 0.574, respectively). Conclusions: Addition of sildenafil to dapagliflozin did not demonstrate any significant clinical or hemodynamic benefit over dapagliflozin monotherapy in HF patients and PH-LHD. Further studies are warranted to evaluate the effects over the long term.<\/jats:p>","DOI":"10.3390\/ph18111663","type":"journal-article","created":{"date-parts":[[2025,11,3]],"date-time":"2025-11-03T16:18:42Z","timestamp":1762186722000},"page":"1663","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Efficacy and Safety of Sildenafil in Combination with Dapagliflozin Versus Dapagliflozin Monotherapy in the Management of Heart Failure with Pulmonary Arterial Hypertension: A Randomized Controlled Trial"],"prefix":"10.3390","volume":"18","author":[{"given":"Esraa M.","family":"Abdallah","sequence":"first","affiliation":[{"name":"Department of Clinical Pharmacy, Faculty of Pharmacy, Fayoum University, Fayoum 63514, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3261-0327","authenticated-orcid":false,"given":"Marwa","family":"Kamal","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacy, Faculty of Pharmacy, Fayoum University, Fayoum 63514, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Khaled","family":"Elkhashab","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Faculty of Medicine, Fayoum University, Fayoum 63514, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3946-5465","authenticated-orcid":false,"given":"Mahmoud A.","family":"Mohamed","sequence":"additional","affiliation":[{"name":"Hikma Pharmaceutical Company, Beni-Suef 62521, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-7174-3839","authenticated-orcid":false,"given":"Ammena Y.","family":"Binsaleh","sequence":"additional","affiliation":[{"name":"Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marwa","family":"Mohsen","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 63511, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0503-685X","authenticated-orcid":false,"given":"Raghda R. S.","family":"Hussein","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacy, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 63511, Egypt"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2025,11,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"352","DOI":"10.1002\/ejhf.2115","article-title":"Endorsed by the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association","volume":"23","author":"Bozkurt","year":"2021","journal-title":"Eur. J. Heart Fail."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"3217","DOI":"10.1016\/j.jacc.2021.04.070","article-title":"Classification of heart failure according to ejection fraction: JACC review topic of the week","volume":"77","author":"Lam","year":"2021","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"3272","DOI":"10.1093\/cvr\/cvac013","article-title":"Global burden of heart failure: A comprehensive and updated review of epidemiology","volume":"118","author":"Savarese","year":"2022","journal-title":"Cardiovasc. Res."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e254","DOI":"10.1161\/CIR.0000000000000950","article-title":"Heart disease and stroke statistics-2021 update: A report from the American Heart Association","volume":"143","author":"Virani","year":"2021","journal-title":"Circulation"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"e11","DOI":"10.15420\/cfr.2023.05","article-title":"Global public health burden of heart failure: An updated review","volume":"9","author":"Shahim","year":"2023","journal-title":"Card. Fail. Rev."},{"key":"ref_6","first-page":"e68117","article-title":"New and Emerging Therapeutic Drugs for the Treatment of Pulmonary Arterial Hypertension: A Systematic Review","volume":"16","author":"Rasheed","year":"2024","journal-title":"Cureus"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"e000137","DOI":"10.1136\/bmjmed-2022-000137","article-title":"Pathophysiology and new advances in pulmonary hypertension","volume":"2","author":"Bousseau","year":"2023","journal-title":"BMJ Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"3988","DOI":"10.21037\/jtd-21-130","article-title":"Echocardiographic signs of pulmonary hypertension in patients with newly recognized hypersensitivity pneumonitis, prevalence and clinical predictors","volume":"13","author":"Dybowska","year":"2021","journal-title":"J. Thorac. Dis."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1552","DOI":"10.1053\/j.jvca.2021.06.036","article-title":"Pulmonary hypertension in 2021: Part I\u2014Definition, classification, pathophysiology, and presentation","volume":"36","author":"Gelzinis","year":"2022","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"107180","DOI":"10.1016\/j.vph.2023.107180","article-title":"The future of group 2 pulmonary hypertension: Exploring clinical trials and therapeutic targets","volume":"151","author":"Awada","year":"2023","journal-title":"Vasc. Pharmacol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1002\/ehf2.14857","article-title":"2024 update in heart failure","volume":"12","author":"Beghini","year":"2025","journal-title":"ESC Heart Fail."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Keller, D.M., Ahmed, N., Tariq, H., Walgamage, M., Walgamage, T., Mohammed, A., Chou, J.T.-T., Ka\u0142u\u017cna-Oleksy, M., Lesiak, M., and Straburzy\u0144ska-Migaj, E. (2022). SGLT2 inhibitors in type 2 diabetes mellitus and heart failure\u2014A concise review. J. Clin. Med., 11.","DOI":"10.3390\/jcm11061470"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/j.ijcard.2021.03.077","article-title":"Effects of SGLT2 inhibitors on cardiovascular, renal, and major safety outcomes in heart failure: A meta-analysis of randomized controlled trials","volume":"332","author":"Li","year":"2021","journal-title":"Int. J. Cardiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1186\/s12933-022-01480-1","article-title":"Direct cardiac effects of SGLT2 inhibitors","volume":"21","author":"Chen","year":"2022","journal-title":"Cardiovasc. Diabetol."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Palmiero, G., Cesaro, A., Vetrano, E., Pafundi, P.C., Galiero, R., Caturano, A., Moscarella, E., Gragnano, F., Salvatore, T., and Rinaldi, L. (2021). Impact of SGLT2 inhibitors on heart failure: From pathophysiology to clinical effects. Int. J. Mol. Sci., 22.","DOI":"10.3390\/ijms22115863"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Crispino, S.P., Segreti, A., Nafisio, V., Valente, D., Crisci, F., Ferro, A., Cavallari, I., Nusca, A., Ussia, G.P., and Grigioni, F. (2025). The role of SGLT2-inhibitors across all stages of heart failure and mechanisms of early clinical benefit: From prevention to advanced heart failure. Biomedicines, 13.","DOI":"10.3390\/biomedicines13030608"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"3599","DOI":"10.1093\/eurheartj\/ehab368","article-title":"2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC","volume":"42","author":"McDonagh","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1007\/s00059-023-05221-2","article-title":"Heart failure: Update of the ESC 2023 guidelines","volume":"49","author":"Bauersachs","year":"2023","journal-title":"Herz"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"e520","DOI":"10.1097\/MJT.0000000000000766","article-title":"Sildenafil for pulmonary arterial hypertension","volume":"26","author":"Bhogal","year":"2019","journal-title":"Am. J. Ther."},{"key":"ref_20","first-page":"215","article-title":"Phosphodiesterase-5 inhibitors for the treatment of pulmonary arterial hypertension","volume":"85","author":"Pulido","year":"2015","journal-title":"Arch. Cardiol. Mex."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"813","DOI":"10.1007\/s12325-009-0064-z","article-title":"Phosphodiesterase type 5 inhibitors in pulmonary arterial hypertension","volume":"26","author":"Montani","year":"2009","journal-title":"Adv. Ther."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Ovchinnikov, A., Potekhina, A., Belyavskiy, E., and Ageev, F. (2022). Heart failure with preserved ejection fraction and pulmonary hypertension: Focus on phosphodiesterase inhibitors. Pharmaceuticals, 15.","DOI":"10.3390\/ph15081024"},{"key":"ref_23","first-page":"309","article-title":"Phosphodiesterase 5 inhibitors for the treatment of heart failure: A systematic review and meta-analysis","volume":"94","author":"Listorti","year":"2024","journal-title":"Arch. Cardiol. Mex."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1016\/S0140-6736(22)01429-5","article-title":"SGLT2 inhibitors in patients with heart failure: A comprehensive meta-analysis of five randomised controlled trials","volume":"400","author":"Vaduganathan","year":"2022","journal-title":"Lancet"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1995","DOI":"10.1056\/NEJMoa1911303","article-title":"Dapagliflozin in patients with heart failure and reduced ejection fraction","volume":"381","author":"McMurray","year":"2019","journal-title":"N. Engl. J. Med."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"819","DOI":"10.1016\/S0140-6736(20)31824-9","article-title":"SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: A meta-analysis of the EMPEROR-Reduced and DAPA-HF trials","volume":"396","author":"Zannad","year":"2020","journal-title":"Lancet"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"550","DOI":"10.1111\/joim.13620","article-title":"SGLT2 inhibition in heart failure with reduced or preserved ejection fraction: Finding the right patients to treat","volume":"293","author":"Girerd","year":"2023","journal-title":"J. Intern. Med."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1268","DOI":"10.1001\/jama.2013.2024","article-title":"Effect of phosphodiesterase-5 inhibition on exercise capacity and clinical status in heart failure with preserved ejection fraction: A randomized clinical trial","volume":"309","author":"Redfield","year":"2013","journal-title":"JAMA"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2565","DOI":"10.1093\/eurheartj\/ehv336","article-title":"Effects of sildenafil on invasive haemodynamics and exercise capacity in heart failure patients with preserved ejection fraction and pulmonary hypertension: A randomized controlled trial","volume":"36","author":"Hoendermis","year":"2015","journal-title":"Eur. Heart J."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1239","DOI":"10.1002\/ejhf.2527","article-title":"Effects of sildenafil on symptoms and exercise capacity for heart failure with reduced ejection fraction and pulmonary hypertension (the SilHF study): A randomized placebo-controlled multicentre trial","volume":"24","author":"Cooper","year":"2022","journal-title":"Eur. J. Heart Fail."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1990","DOI":"10.1002\/ejhf.2622","article-title":"Particular challenges in the use of pulmonary vasodilating therapy for patients with pulmonary hypertension secondary to left heart disease. Letter regarding the article \u2018Effects of sildenafil on symptoms and exercise capacity for heart failure with reduced ejection fraction and pulmonary hypertension (the SilHF study): A randomized placebo-controlled multicentre trial\u2019","volume":"24","author":"Dandel","year":"2022","journal-title":"Eur. J. Heart Fail."},{"key":"ref_32","first-page":"309","article-title":"Inhibidores de la fosfodiesterasa 5 para el tratamiento de la insuficiencia cardiaca: Revisi\u00f3n sistem\u00e1tica y metaan\u00e1lisis de ensayos cl\u00ednicos aleatorizados","volume":"94","author":"Listorti","year":"2024","journal-title":"Arch. Cardiol. Mex."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Vitale, G., Romano, G., Di Franco, A., Caccamo, G., Nugara, C., Ajello, L., Storniolo, S., Sarullo, S., Agnese, V., and Giallauria, F. (2019). Early effects of sacubitril\/valsartan on exercise tolerance in patients with heart failure with reduced ejection fraction. J. Clin. Med., 8.","DOI":"10.3390\/jcm8020262"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1016\/j.hrtlng.2025.04.027","article-title":"Clinical outcomes of sacubitril-valsartan versus angiotensin converting enzyme inhibitor or angiotensin receptor blocker among patients with heart failure and ejection fraction at\/less than 60%: A retrospective, observational, parallel cohort, multi-group study","volume":"73","author":"Albert","year":"2025","journal-title":"Heart Lung"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1016\/j.cardfail.2007.11.006","article-title":"Effects of 5\u2032-phosphodiesterase four-week long inhibition with sildenafil in patients with chronic heart failure: A double-blind, placebo-controlled clinical trial","volume":"14","author":"Behling","year":"2008","journal-title":"J. Card. Fail."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"2136","DOI":"10.1016\/j.jacc.2007.07.078","article-title":"Long-term use of sildenafil in the therapeutic management of heart failure","volume":"50","author":"Guazzi","year":"2007","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1555","DOI":"10.1161\/CIRCULATIONAHA.107.716373","article-title":"Sildenafil improves exercise capacity and quality of life in patients with systolic heart failure and secondary pulmonary hypertension","volume":"116","author":"Lewis","year":"2007","journal-title":"Circulation"},{"key":"ref_38","unstructured":"Smith, B.P., and Babos, M. (2020). Sildenafil, StatPearls Publishing."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"108861","DOI":"10.1016\/j.pharmthera.2025.108861","article-title":"Cardiovascular therapeutic targets of sodium-glucose co-transporter 2 (SGLT2) inhibitors beyond heart failure","volume":"270","author":"Armillotta","year":"2025","journal-title":"Pharmacol. Ther."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Belyavskiy, E., Ovchinnikov, A., Potekhina, A., Ageev, F., and Edelmann, F. (2020). Phosphodiesterase 5 inhibitor sildenafil in patients with heart failure with preserved ejection fraction and combined pre-and postcapillary pulmonary hypertension: A randomized open-label pilot study. BMC Cardiovasc. Disord., 20.","DOI":"10.1186\/s12872-020-01671-2"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"941","DOI":"10.1016\/j.amjmed.2025.01.028","article-title":"Diagnosis: Pulmonary Hypertension. Next Steps","volume":"138","author":"Gelfman","year":"2025","journal-title":"Am. J. Med."},{"key":"ref_42","first-page":"1010","article-title":"SGLT-2 Inhibitors: Focus on Dapagliflozin","volume":"32","author":"Siddiqui","year":"2024","journal-title":"Cardiol. Rev."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"372","DOI":"10.3122\/jabfm.2023.230455R1","article-title":"GLP-1 RAs and SGLT2-Is to lower glucose and reduce the risk of Cardiovascular and Diabetic kidney disease","volume":"37","author":"Morrison","year":"2024","journal-title":"J. Am. Board Fam. Med."},{"key":"ref_44","unstructured":"Weir, C., and Jan, A. (2023). BMI Classification Percentile and Cut off Points, StatPearls."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"e263","DOI":"10.1016\/j.jacc.2021.12.012","article-title":"2022 AHA\/ACC\/HFSA guideline for the management of heart failure: A report of the American College of Cardiology\/American Heart Association Joint Committee on Clinical Practice Guidelines","volume":"79","author":"Heidenreich","year":"2022","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1089","DOI":"10.1056\/NEJMoa2206286","article-title":"Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction","volume":"387","author":"Solomon","year":"2022","journal-title":"N. Engl. J. Med."}],"container-title":["Pharmaceuticals"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1424-8247\/18\/11\/1663\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,4]],"date-time":"2025-11-04T11:26:12Z","timestamp":1762255572000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1424-8247\/18\/11\/1663"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,3]]},"references-count":46,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2025,11]]}},"alternative-id":["ph18111663"],"URL":"https:\/\/doi.org\/10.3390\/ph18111663","relation":{},"ISSN":["1424-8247"],"issn-type":[{"type":"electronic","value":"1424-8247"}],"subject":[],"published":{"date-parts":[[2025,11,3]]}}}