What are the effects of tadalafil in heart failure?

From the Guidelines

Tadalafil should be used with caution in patients with heart failure, as its effects on this condition are not fully understood and may vary depending on the individual patient's circumstances 1.

Key Considerations

• The medication may improve exercise tolerance and reduce symptoms of heart failure in some patients, particularly those with pulmonary arterial hypertension, as evidenced by a mean placebo-corrected increase in 6MWD of 33m in patients receiving 40mg of tadalafil daily 1.
• However, it can also increase the risk of worsening heart failure, particularly in those with severe left ventricular dysfunction.
• Patients with heart failure should be advised to take tadalafil under the guidance of a healthcare provider, and their condition should be closely monitored for any signs of deterioration.

Dosage and Monitoring

• It is recommended to start with a low dose of 10mg and monitor the patient's condition closely, as the safety and efficacy of tadalafil in heart failure patients have not been extensively studied 1.
• The dose may be increased to 20mg if tolerated, but it is essential to weigh the potential benefits against the risks and adjust the treatment plan accordingly.

Collaborative Approach

• Management of erectile dysfunction in patients with heart failure should always be considered secondary to maintaining cardiovascular function, and treatment for ED should not negatively affect cardiovascular health 1.
• A collaborative approach to the management of men's sexual function and cardiovascular risk, incorporating general, urologic, endocrine, and cardiologic expertise, is recommended to ensure the safe and effective use of tadalafil in patients with heart failure.

From the FDA Drug Label

The following groups of patients with cardiovascular disease were not included in clinical safety and efficacy trials for tadalafil, and therefore until further information is available, tadalafil is not recommended for the following groups of patients: ... New York Heart Association Class 2 or greater heart failure in the last 6 months... Patients with left ventricular outflow obstruction, (e.g., aortic stenosis and idiopathic hypertrophic subaortic stenosis) can be sensitive to the action of vasodilators, including PDE5 inhibitors As with other PDE5 inhibitors, tadalafil has mild systemic vasodilatory properties that may result in transient decreases in blood pressure

The effects of tadalafil in heart failure are not well established, and it is not recommended for patients with New York Heart Association Class 2 or greater heart failure in the last 6 months due to lack of clinical safety and efficacy trials 2. Tadalafil has mild systemic vasodilatory properties that may result in transient decreases in blood pressure, which could be a concern in patients with heart failure. Caution should be exercised when considering the use of tadalafil in patients with heart failure.

From the Research

Effects of Tadalafil on Heart Failure

• Tadalafil, a phosphodiesterase type 5 (PDE5) inhibitor, has been shown to have both positive and negative effects on heart failure in various studies 3, 4, 5, 6, 7.
• In a case report, low-dose tadalafil improved hemodynamics in a patient with biventricular heart failure, allowing for an increase in the dose of renin-angiotensin-aldosterone system (RAAS) inhibitors 3.
• However, a randomized controlled phase 3 study found that tadalafil did not improve outcomes in patients with heart failure with preserved ejection fraction and combined postcapillary and precapillary pulmonary hypertension, and may even increase the risk of all-cause mortality 4.
• Animal studies have shown that tadalafil can prevent acute heart failure with reduced ejection fraction in mice, and improve left ventricular diastolic function in resistant hypertension 5, 6.
• Tadalafil has also been shown to have cardiovascular-protective effects, including improving endothelial function and increasing nitric oxide levels, which may be beneficial for patients with heart failure 7.

Mechanisms of Action

• Tadalafil works by inhibiting PDE5, which increases the levels of cyclic guanosine monophosphate (cGMP) and nitric oxide, leading to vasodilation and improved cardiac function 5, 6, 7.
• The increase in cGMP and nitric oxide levels can also lead to improved endothelial function and reduced pulmonary vascular resistance, which may be beneficial for patients with heart failure 5, 6, 7.

Clinical Implications

• The use of tadalafil in patients with heart failure should be carefully considered, taking into account the potential benefits and risks, as well as the individual patient's underlying condition and medical history 3, 4.
• Further studies are needed to fully understand the effects of tadalafil on heart failure and to determine its potential role in the treatment of this condition 4, 5, 6, 7.