Background
Methods
Data sources and searches
Study selection
Data extraction and quality assessment
Study | Design | Condition | Treatment | Dose and time | Number of patients (PP) | Mean age (SD) or age range |
---|---|---|---|---|---|---|
R, DB, PC | HAPH | S | 25 mg x 3/die | 9S versus 8P | 61 (8) | |
100 mg x 3/die 12 weeks | 5S versus 8P | |||||
R, DB, PC | HFrEF | S | 25 mg x 2/die - >2 weeks | 53S versus 51P | S: 51.29 (14.80) | |
Then | ||||||
50 mg x 3/die - >10 weeks | P: 50.61 (4.18) | |||||
R, DB, PC | Diastolic Dysfunction after MI | S | 40 mg x 3/die 9 weeks | 34S versus 33P | S: 63 (8) | |
P: 62 (7) | ||||||
R, DB, PC | PAH-CTD | S | 20 mg x 3/die | 21 S | S: 52 (15) | |
40 mg x 3/die | 20 S | 50 (15) | ||||
80 mg x 3/die | 19 S | 54 (14) | ||||
12 weeks | 22 P | P: 56 (14) | ||||
R, DB, PC | CHF | S | 50 mg x 3/die | 11S versus 8P | S: 45 (12) | |
4 weeks | P: 53 (11) | |||||
R, DB, PC | PAH due to congenital left to right shunt | T | 20 mg x 3 | 8 T - P | 28 (9.38) | |
CO (wo:2 wks) | 4 weeks | |||||
R, DB, PC | ED VRF | T | 20 mg every other day | 18 T versus 18P | T: 52.05 (8.98) | |
12 weeks | P: 49.61 (12.68) | |||||
R, DB, PC | PAH | S | 20 mg x 3/die | 65 S | S: 47 (14) | |
40 mg x 3/die | 63 S | 51 (15) | ||||
80 mg x 3/die | 65 S | 48 (18) | ||||
12 weeks | 65 P | P: 49 (17) | ||||
R, DB, PC | Diabetic Cardiomyopathy | S | 25 + 25+ 50 mg/die | 29S versus 25P | S: 60.7 (7.6) | |
3 months | P: 60.2 (8.3) | |||||
R, DB, PC | CHD after Fontan Operation | S | 20 mg x 3/die | 27 S - P | 14.9 (5.1) | |
CO (wo:6 wks) | 6 weeks | |||||
R, DB, PC | CHD after Fontan Operation | S | 20 mg x 3/die | 27 S - P | 14.9 (5.1) | |
CO (wo:6 wks) | 6 weeks | |||||
R, DB, PC | CRPS | T | 10 mg/die - >4 weeks | 12 T versus12P | T: 39.8 (13.1) | |
Then | P: 36.5 (10.6) | |||||
20 mg/die - >8 weeks | ||||||
R, DB, PC | CHF | S | 50 mg x 3/die | 23S versus 23P | S: 62 (3) | |
6 months | P: 63 (4) | |||||
R, DB, PC | HFpEF with PAH | S | 50 mg x 3/die | 22S versus 22P | 53-79 | |
12 months | ||||||
R, DB, PC | Systolic HF | S | 50 mg x 3/die | 23S versus 22P | S: 60 (4) | |
12 months | P: 61 (4) | |||||
R, DB, PC | EOB in HF | S | 50 mg x 3/die | 16S versus 16P | S: 66 (8) | |
12 months | P: 68 (6) | |||||
R, DB, PC | PAH | V | 5 mg/die - >4 weeks | 43 V versus 16P | S: 32 (12) | |
then | ||||||
5 mg x 2/die - >8 weeks | P: 29 (8) | |||||
R, DB, PC | Systolic HF and secondary PAH | S | 25 to 75 mg x 3/die | 17S versus 17P | S: 54 (4) | |
12 weeks | P: 62 (3) | |||||
R, DB, PC | Systolic HF and secondary PAH | S | 25 to 75 mg x 3/die | 15S versus 15P | S: 54 (4) | |
12 weeks | P: 62 (3) | |||||
R, DB, PC | ED VRF | T | 20 mg every other day | 16 T versus 16P | 65.4 (6.3) | |
4 weeks | ||||||
R, DB, PC | HFpEF | S | 20 mg x 3/die - >12 weeks | 49S versus 47Pa
| 62-77 | |
then 60 mg x 3/die -> | 45S versus 58Pb
| |||||
12 weeks | 95S versus 94Pc
| |||||
R, DB, PC | PAH | S | 25 to 100 mg x 3/die | 20 S - P | 16-55 | |
CO (wo:0) | 6 weeks | |||||
R, DB, PC | CTEPH | S | 40 mg x 3/die | 8S versus 10P | S: 49.9 (13.1) | |
12 weeks | P: 60 (14.4) | |||||
R, DB, PC | ED | V | 5 to 20 mg/die | 175 V versus 175P | V:22-76 | |
12 weeks | P: 22-78 |
Outcomes
Data synthesis and analysis
Results
Study selection
Study characteristics
Risk of bias
Synthesis of results
Efficacy data: PDE-inhibitors versus placebo
Cardiac geometry
Main analysis | LVMi g/m2
| EDVi ml/m2
| IVS Mm | VTD mm | Cardiac index L/min/m2
| EF% | E/A ratio | NTpro-BNP pg/ml | HR bpm | MAP mmHg | SBP mmHg | DBP mmHg | SVRi dynes m2/sec cm-5
| FMD% |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
WMD
| -4.022 | 0.433 | -0.966 | -2.666 | 0.304 | 3.561 | 0.053 | -161.9 | -0.848 | -0.413 | 0.616 | -0.763 | -88.34 | 3.306 |
Lower 95% CI | -10.137 | -6.49 | -2.230 | -7.145 | 0.202 | 1.786 | -0.275 | -351.5 | -2.398 | -3.023 | -1.113 | -2.174 | -255.75 | 0.530 |
Upper 95% CI | 2.093 | 7.357 | 0.298 | 1.814 | 0.406 | 5.335 | 0.380 | 27.6 | 0.702 | 2.196 | 2.345 | 0.648 | 79.08 | 6.082 |
---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | --- |
Number
|
306
|
262
|
98
|
99 | 520 |
286
|
116
|
407
|
977
|
355
|
828
|
791
|
232
|
168
|
P value
|
0.197
|
0.902
|
0.134
|
0.243
|
<0.001
|
<0.001
|
0.753
|
0.094
|
0.283
|
0.756
|
0.490
|
0.289
|
0.301
|
0.020
|
I-square | 96% | 94% | 95% | 90% | 0.0% | 84% | 93% | 82% | 56% | 71% | 49% | 52% | 89% | 99% |
References | ||||||||||||||
Subgroup/ Sensitivity
a
|
LVMi g/m
2
|
EDVi ml/m
2
|
IVS Mm
|
VTD mm
|
Cardiac index L/min/m
2
|
EF %
|
E/A ratio
|
NTpro-BNP Pg/ml
|
HR bpm
|
MAP mmHg
|
SBP mmHg
|
DBP mmHg
|
SVRi dynes m
2
/sec cm
-5
|
FMD%
|
LVH
| -12.207 | 0.082 | 4.382 | 0.053 | -486.7 | 0.829 | 1.156 | 0.135 | -1.936 | 55.63 | / | |||
Lower 95% CI | -18.846 | / | / | / | -0.176 | 2.059 | -0.275 | -712,8 | -4.526 | -2.398 | -2.598 | -5.309 1.438 | -277.86 | |
Upper 95% CI | -5.568 | 0.341 | 6.705 | 0.380 | -260,7 | 6.185 | 4.710 | 2.867 | ---- | 389.12 | ||||
--- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | |||||
Number
|
89
|
62
|
119
|
116
|
97
|
57
|
74
|
72
|
116
|
74
| ||||
P value
|
<0.001
|
/
|
/
|
/
|
0.534
|
<0.001
|
0.753
|
<0.001
|
0.761
|
0.524
|
0.923
|
0.261
|
0.744
|
/
|
I-square | 88% | / |
/
|
/
| 0.0% | 79% | 93% | 0.0% | 0.0% | 0.0% | 0.0% | 66% | 88% | / |
Non-LVH
| 1.404 | 4.999a
| 0.354 | 0.973 | -11.20 | 0.691 | 0.613 | -0.635 | / | / | ||||
Lower 95% CI | -1.908 | 3.286 | / | / | 0.165 | -1.329 | / | -160.8 | -2.330 | / | -5.161 | -9.278 8.008 | ||
Upper 95% CI | 4.717 | 6.711 | 0.544 | 3.274 | 138.4 | 3.713 | 6.388 | ---- | ||||||
---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | |||||||
Number
|
217
|
217
|
121
|
121
|
310
|
121
|
224
|
121
| ||||||
P value
|
0.406
|
<0.001
|
/
|
/
|
<0.001
|
0.408
|
/
|
0.883
|
0.654
|
/
|
0.835
|
0.886
|
/
|
/
|
I-square | 80% | 0.0% | / | / | 0.0% | 0.0% |
/
| 75% | 0.0% | / | 79% | 91% | / | / |
Left heart disease
| -4.022 | 0.433 | -0.966 | -2.666 | 0.298 | 3.561 | 0.053 | -149.7a
| 0.651 | -0.951 | 0.079a
| -1.352 | -70.97 | 2.686 |
Lower 95% CI | -10.137 2.093 | -6.49 7.357 | -2.230 0.298 | -7.145 1.814 | 0.134 | 1.786 5.335 | -0.275 | -352.4 | -2.781 4.084 | -4.377 2.474 | -2.610 2.768 | -3.932 1.227 | -273.90 | -2.635 8.008 |
Upper 95% CI | 0.461 | 0.380 | 53.0 | 131.95 | ||||||||||
---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- |
Number
|
306
|
262
|
98
|
99 |
165
|
286
|
116
|
389
|
229
|
252
|
419
|
360
|
173
|
100
|
P value
|
0.197
|
0.902
|
0.134
|
0.243
|
<0.001
|
<0.001
|
0.753
|
0.148
|
0.710
|
0.586
|
0.954
|
0.304
|
0.493
|
0.322
|
I-square | 96% | 94% | 95% | 90% | 0.0% | 84% | 93% | 84% | 81% | 75% | 66% | 75% | 91% | 99% |
Subgroup/ Sensitivity
a
|
LVMi g/m
2
|
EDVi ml/m
2
|
IVS Mm
|
VTD mm
|
Cardiac index L/min/m
2
|
EF%
|
E/A ratio
|
NTpro-BNP Pg/ml
|
HR bpm
|
MAP mmHg
|
SBP mmHg
|
DBP mmHg
|
SVRi dynes m
2
/sec cm
-5
|
FMD%
|
Right heart disease
| 0.309 | -2.700 | 0.867 | |||||||||||
Lower 95% CI | / | / | / | / | 0.178 | / | / | / | -4.554 | / | / | -2.637 4.372 | / | / |
Upper 95% CI | 0.439 | -0.847 | ||||||||||||
---- | ---- | ---- | ---- | |||||||||||
Number
|
355
|
347
|
30
| |||||||||||
P value
|
/
|
/
|
/
|
/
|
<0.001
|
/
|
/
|
/
|
0.004
|
/
|
/
|
0.628
|
/
|
/
|
I-square |
/
|
/
|
/
|
/
| 0.0% |
/
|
/
|
/
| 0.0% |
/
|
/
| 0.0% |
/
|
/
|
Non-cardiac disease
| -0.109 | 0.107 | 0.073 | 3.953 | ||||||||||
Lower 95% CI | / | / | / | / | / | / | / | / | -2.723 | / | -2.287 | -1.515 1.660 | / | 1.240 |
Upper 95% CI | 2.504 | 2.502 | 6.667 | |||||||||||
---- | ---- | ---- | ---- | ---- | ||||||||||
Number
|
374
|
374
|
374
|
68
| ||||||||||
P value
|
/
|
/
|
/
|
/
|
/
|
/
|
/
|
/
|
0.935
|
/
|
0.930
|
0.928
|
/
|
0.004
|
I-square |
/
|
/
|
/
|
/
|
/
|
/
|
/
|
/
| 0.0% | / | 0.0% | 0.0% | / | 96% |
Age <60 yrs
| 0.284 | 3.187 | 0.173
a
| 1.940 | -0.008 | -0.292 | -130.44 | |||||||
Lower 95% CI | 0.163 | -0.716 | -0.150 | -0.824 | -2.023 | -1.631 1.047 | -234.44 | / | ||||||
Upper 95% CI | / | / | / | / | 0.405 | 7.089 | 0.496 | / | / | 4.704 | 2.006 | ---- | -26.43 | |
---- | ---- | ---- | ---- | ---- | ---- |
513
| ---- | |||||||
Number
|
399
|
74
|
71
|
212
|
513
|
89
| ||||||||
P value
|
/
|
/
|
/
|
/
|
0.000
|
0.110
|
0.295
|
/
|
/
|
0.196
|
0.993
|
0.669
|
0.014
|
/
|
I-square | / | / | / | / | 0.0% | 80% | 90% | / | / | 0.0% | 0.0% | 0.0% | 0.0% |
/
|
Age
-
60 yrs
| -2.683a
| 0.433 | -2.666 | 0.354 | 2.582 | -40.199
a
| -0.491 | -2.349 | 0.663 | -2.048 | -57.48 | 3.558a
| ||
Lower 95% CI | -9.169 | -6.49 | / | -7.145 1.814 | 0.165 | -1.074 | / | -196.023 | -3.826 | -5.851 | -2.067 | -4.741 0.646 | -349.32 | 0.306 |
Upper 95% CI | 3.804 | 7.357 | ---- | 0.544 | 6.237 | 115.624 | 2.844 | 1.153 | 3.392 | 234.36 | 6.809 | |||
---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | |||
Nymber
|
262
|
262
|
99
|
121
|
167
|
355
|
221
|
143
|
315
|
234
|
143
|
132
| ||
P value
|
0.418
|
0.902
|
/
|
0.243
|
<0.001
|
0.166
|
/
|
0.613
|
0.773
|
0.189
|
0.634
|
0.136
|
0.699
|
0.032
|
I-square | 95% | 94% | / | 90% | 0.0% | 90% | / | 72% | 79% | 83% | 72.% | 71% | 94% | 99% |
Subgroup/ Sensitivity
a
|
LVMi g/m
2
|
EDVi ml/m
2
|
IVS Mm
|
VTD mm
|
Cardiac index L/min/m
2
|
EF%
|
E/A ratio
|
NTpro-BNP Pg/ml
|
HR bpm
|
MAP mmHg
|
SBP mmHg
|
DBP mmHg
|
SVRi dynes m
2
/sec cm
-5
|
FMD%
|
Sildenafil
| -4.022 | 0.433 | -0.966 | -2.666 | 0.289a
| 3.561 | 0.053 | -161.9 | -0.943 | -0.880a
| 0.248 | -0.995 | -70.9 | 2.7 |
Lower 95% CI | -10.137 | -6.49 | -2.230 | -7.145 1.814 | 0.179 | 1.786 | -0.275 | -351.5 | -2.959 | -3.642 | -2.138 | -2.852 0.863 | -273.9 | -2.6 |
Upper 95% CI | 2.093 | 7.357 | 0.298 | 0.399 | 5.335 | 0.380 | 27.6 | 1.073 | 1.882 | 2.634 | 131.9 | 8.0 | ||
--- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- | ---- |
Number
|
306
|
262
|
98
|
99 |
461
|
286
|
116
|
407
|
536
|
296
|
446
|
409
|
173
|
100
|
P value
|
0.197
|
0.902
|
0.134
|
0.243
|
<0.001
|
<0.001
|
0.753
|
0.094
|
0.359
|
0.532
|
0.839
|
0.294
|
0.493
|
0.322
|
I-square | 96% | 94% | 95% | 90% | 0.0% | 84% | 93% | 82% | 0.0% | 72% | 60% | 63% | 91% | / |
Tadalafil
| -1.033 | 4.659 | 1.101 | 3.953 | ||||||||||
Lower 95% CI | -7.141 | -2.529 | / | 1.240 | ||||||||||
Upper 95% CI | / | / | / | / | / | / | / | / | 5.075 | / | 11.846 | -4.717 6.920 | 6.667 | |
--- | ---- | ---- | ---- | ---- | ||||||||||
Number | 32 | 32 | 32 | 68 | ||||||||||
P value | / | / | / | / | / | / | / | / | 0.740 | / | 0.204 | 0.711 | / |
0.004
|
I-square | / | / | / | / | / | / | / | / | 0.0% | / | 0.0% | 0.0% | / |
/
|
Vardenafil
| -0.408 | |||||||||||||
Lower 95% CI | -3.746 | |||||||||||||
Upper 95% CI | / | / | / | / | / | / | / | / | 2.931 | / | / | / | / | / |
--- | ---- | |||||||||||||
Number | 409 | |||||||||||||
P value | / | / | / | / | / | / | / | / | 0.811 | / | / | / | / | / |
I-square | / | / | / | / | / | / | / | / | 0.0% | / | / | / | / | / |