Combined Inhibition of Phosphodiesterase-5 and -9 in Experimental Heart Failure

JACC Heart Fail. 2024 Jan;12(1):100-113. doi: 10.1016/j.jchf.2023.08.028. Epub 2023 Nov 1.


Background: Intracellular second messenger cyclic guanosine monophosphate (cGMP) mediates bioactivity of the natriuretic peptides and nitric oxide, and is key to circulatory homeostasis and protection against cardiovascular disease. Inhibition of cGMP-degrading phosphodiesterases (PDEs) PDE5 and PDE9 are emerging as pharmacological targets in heart failure (HF).

Objectives: The present study investigated dual enhancement of cGMP in experimental HF by combining inhibition of PDE-5 (P5-I) and PDE-9 (P9-I).

Methods: Eight sheep with pacing-induced HF received on separate days intravenous P5-I (sildenafil), P9-I (PF-04749982), P5-I+P9-I, and vehicle control, in counterbalanced order.

Results: Compared with control, separate P5-I and P9-I significantly increased circulating cGMP concentrations in association with reductions in mean arterial pressure (MAP), left atrial pressure (LAP), and pulmonary arterial pressure (PAP), with effects of P5-I on cGMP, MAP, and PAP greater than those of P9-I. Only P5-I decreased pulmonary vascular resistance. Combination P5-I+P9-I further reduced MAP, LAP, and PAP relative to inhibition of either phosphodiesterase alone. P9-I and, especially, P5-I elevated urinary cGMP levels relative to control. However, whereas inhibition of either enzyme increased urine creatinine excretion and clearance, only P9-I induced a significant diuresis and natriuresis. Combined P5-I+P9-I further elevated urine cGMP with concomitant increases in urine volume, sodium and creatinine excretion, and clearance similar to P9-I alone, despite the greater MAP reductions induced by combination treatment.

Conclusions: Combined P5-I+P9-I amalgamated the superior renal effects of P9-I and pulmonary effects of P5-1, while concurrently further reducing cardiac preload and afterload. These findings support combination P5-I+P9-I as a therapeutic strategy in HF.

Keywords: cyclic guanosine monophosphate; heart failure; natriuretic peptides; nitric oxide; phosphodiesterase 5; phosphodiesterase 9.

MeSH terms

  • Animals
  • Creatinine
  • Cyclic GMP
  • Cyclic Nucleotide Phosphodiesterases, Type 5 / therapeutic use
  • Heart Failure* / drug therapy
  • Humans
  • Phosphodiesterase Inhibitors / pharmacology
  • Phosphodiesterase Inhibitors / therapeutic use
  • Sheep


  • Cyclic Nucleotide Phosphodiesterases, Type 5
  • Creatinine
  • Phosphodiesterase Inhibitors
  • Cyclic GMP