Sildenafil is a selective phosphodiesterase-5 inhibitor and causes vasodilatation, particularly in pulmonary circulation. Since left heart failure may be associated with pulmonary hypertension "out of proportion to left heart disease," sildenafil may have beneficial effect in such patients. The present investigation was designed as a 12-week, single-center, randomized, double-blind, placebo-controlled study evaluating the effects of sildenafil on mean blood pressure (primary endpoint) in patients with left systolic heart failure. Secondary endpoints included exercise capacity assessed by 6-minute walk test. A total of 106 patients were randomized 1:1 to sildenafil (n=53) or placebo (n=53). Patients received sildenafil 25 mg twice a day or matching placebo for the first 2 weeks and 50 mg 3 times a week for the remainder of the trial. The placebo-corrected effect on mean blood pressure was 1.16 mm Hg (95% confidence interval, -1.6 to 5.1, P>.05), demonstrating that sildenafil did not decrease mean blood pressure. Compared with placebo, sildenafil increased the 6-minute walk test by a nonsignificant treatment effect of 14 m (P=.67). Adverse effects occurred in a comparable proportion of patients taking sildenafil and placebo, and none of the patients needed to discontinue therapy. Sildenafil is well tolerated in left heart failure patients and does not decrease blood pressure. It can be safely added to standard heart failure therapy.

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IntroductionAnkylosing spondylitis (AS) is a chronic inflammatory condition that most commonly affects the axial skeleton, including the spine and sacroiliac joints. The most common cardiac manifestation in patients with AS is the aortic root and valve disease, which has been reported in up to 82% of patients (1). Other less common cardiac abnormalities that are observed in patients with AS include conduction and rhythm abnormalities, decreased coronary flow reserve, myocardial infarction, and diastolic dysfunction. However, the presence of systolic dysfunction has been less described in patients with AS. Herein we present two cases of idiopathic dilated cardiomyopathy in patients with AS. These patients were noted to have an improvement of their ejection fractions following treatment of AS, suggesting that cardiomyopathy in AS may be reversible with an effective treatment of the underlying inflammatory process. Written informed consent was obtained from patients who participated in this study. Case PresentationsCase 1 A 25-year-old man, with a known case of AS since 18 months, was referred to our Heart Failure Clinic with the New York Heart Association (NYHA) function class II of dyspnea on exertion. Heart failure was diagnosed prior to his rheumatologic problem, and he was partially treated using an angiotensin-converting enzyme inhibitor [captopril (Captopril, Rouz Darou; Tehran, Iran) 25 mg/BID (i.e., two times a day)] only. Complete rheumatologic panels were ordered, which established the presence of a seronegative spondyloarthropathy. He was receiving indomethacin (Indomethacin, Loghman; Tehran, Iran), sulfasalazine (Sulfasalazine, Mehr Darou; Tehran, Iran), and prednisolone (Prednisolone, Iran Hormone; Tehran, Iran) for AS. Sulfasalazine and prednisolone were initiated after an AS diagnosis, and the doses were maintained at 2000 and 2.5 mg daily, respectively.On arrival to our clinic, his cardiovascular examination revealed a regular heart rate, normal S1 and S2, and left-sided S3. No jugular venous distension was noted. The baseline echocardiography revealed mild left ventricular (LV) enlargement with severe systolic dysfunction [left ventricular ejection fraction (LVEF)=30%] and grade 2 diastolic dysfunction, normal right ventricular (RV) size and function, estimated systolic pulmonary artery pressure of 30 mmHg, no aortic stenosis or regurgitation, mild mitral regurgitation, and mild tricuspid regurgitation. Tissue Doppler study confirmed a reduced systolic myocardial velocity and a significant diastolic dysfunction. A complete laboratory examination, including electrocardiogram, calcium and magnesium levels, complete blood test, liver function tests, renal function tests (blood urea nitrogen and creatinine levels), serum electrolyte levels, thyroid-stimulating hormone levels, hemoglobin A1C, lipid profile, human immunodeficiency virus serological screening, and antinuclear antibody titer, 179Ankylosing spondylitis (AS) is a chronic inflammatory condition that most commonly affects the axial ...