Research

JAMA Cardiology | Brief Report

Sildenafil Treatment in Heart Failure

With Preserved Ejection Fraction
Targeted Metabolomic Profiling in the RELAX Trial
Hanghang Wang, MD; Kevin Anstrom, PhD; Olga Ilkayeva, PhD; Michael J. Muehlbauer, PhD; James R. Bain, PhD; Steven McNulty, MS;
Christopher B. Newgard, PhD; William E. Kraus, MD; Adrian Hernandez, MD; G. Michael Felker, MD; Margaret Redfield, MD; Svati H. Shah, MD

Supplemental content
IMPORTANCE Phosphodiesterase-5 inhibition with sildenafil compared with a placebo had no
effect on the exercise capacity or clinical status of patients with heart failure with preserved
ejection fraction (HFpEF) in the PhosphodiesteRasE-5 Inhibition to Improve Clinical Status
and Exercise Capacity in Diastolic Heart Failure with Preserved Ejection Fraction (RELAX)
clinical trial. Metabolic impairments may explain the neutral results.

OBJECTIVE To test the hypothesis that profiling metabolites in the RELAX trial would clarify
the mechanisms of sildenafil effects and identify metabolites associated with clinical
outcomes in HFpEF.

DESIGN, SETTING, AND PARTICIPANTS Paired baseline and 24-week plasma samples of 160
stable outpatient individuals with HFpEF enrolled in the RELAX clinical trial were analyzed
using flow injection tandem mass spectrometry (60 metabolites) and conventional assays
(5 metabolites).

INTERVENTIONS Sildenafil (n = 79) or a placebo (n = 81) administered orally at 20 mg, 3 times

daily for 12 weeks, followed by 60 mg, 3 times daily for 12 weeks.

MAIN OUTCOMES AND MEASURES The primary measure was metabolite level changes
between baseline and 24 weeks stratified by treatments. Secondary measures included
correlations between metabolite level changes and clinical biomarkers and associations
between baseline metabolite levels and the composite clinical score.

RESULTS No metabolites changed between baseline and 24 weeks in the group treated with
a placebo; however, 7 metabolites changed in the group treated with sildenafil, including
decreased amino acids (alanine and proline; median change [25th-75th], 38.26 [100.3 to
28.19] and 28.24 [56.29 to 12.08], respectively; false discovery rateadjusted P = .01 and
.03, respectively), and increased short-chain dicarboxylacylcarnitines glutaryl carnitine, Author Affiliations: Duke Molecular
octenedioyl carnitine, and adipoyl carnitine (median change, 6.19 [3.37 to 14.18], 2.72 [3 to Physiology Institute, Duke University
12.57], and 10.72 [11.23 to 29.57], respectively; false discovery rateadjusted P = .01, .04, and School of Medicine, Durham, North
Carolina (Wang, Ilkayeva,
.05, respectively), and 1 long-chain acylcarnitine metabolite (palmitoyl carnitine; median Muehlbauer, Bain, Newgard, Kraus,
change, 7.83 [5.64 to 26.99]; false discovery rateadjusted P = .03). The increases in Shah); Department of Biostatistics
long-chain acylarnitine metabolites and short-chain dicarboxylacylcarnitines correlated with and Bioinformatics, Duke University
School of Medicine, Durham, North
increases in endothelin-1 and creatinine/cystatin C, respectively. Higher baseline levels of
Carolina (Anstrom); Duke Clinical
short-chain dicarboxylacylcarnitine metabolite 3-hydroxyisovalerylcarnitine/malonylcarnitine Research Institute, Duke University
and asparagine/aspartic acid were associated with worse clinical rank scores in both School of Medicine, Durham, North
treatment groups (, 96.60, P = .001 and , 0.02, P = .01; after renal adjustment, P = .09 Carolina (Anstrom, McNulty,
Hernandez, Felker, Shah); Division of
and .02, respectively). Cardiology, Department of Medicine,
Duke University School of Medicine,
CONCLUSIONS AND RELEVANCE Our study provides a potential mechanism for the effects of Durham, North Carolina (Kraus,
Hernandez, Felker, Shah);
sildenafil that, through adverse effects on mitochondrial function and endoplasmic reticulum
Department of Medicine, Mayo Clinic,
stress, could have contributed to the neutral trial results in RELAX. Short-chain Rochester, Minnesota (Redfield).
dicarboxylacylcarnitine metabolites and asparagine/aspartic acid could serve as biomarkers Corresponding Author: Svati H.
associated with adverse clinical outcomes in HFpEF. Shah, MD, MS, MHS, Duke Molecular
Physiology Institute, 300 N Duke St,
JAMA Cardiol. doi:10.1001/jamacardio.2017.1239 Durham NC 27701 (svati.shah@duke
Published online May 10, 2017. .edu).

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 Research Brief Report
H
eart failure with preserved ejection fraction (HFpEF)
is a complex syndrome associated with many diag-
nostic and therapeutic challenges.1 A recent clinical
trial, Phosphodiesterase-5 Inhibition to Improve Clinical Sta-
tus and Exercise Capacity in Heart Failure with Preserved Ejec-
tion Fraction (RELAX),2 did not demonstrate improvements
in exercise capacity or clinical status of patients with HFpEF
who were treated with sildenafil compared with participants
treated with a placebo. In this study, we performed quantita-
tive, targeted metabolomic profiling in RELAX samples to ex-
amine the underlying mechanisms modified by sildenafil that
could have mediated the neutral trial results and to identify
biomarkers associated with clinical outcomes.
Methods
Study Cohort
The RELAX trial2 was a multicenter, double-blind trial con-
ducted through the Heart Failure Clinical Research Network
from 2008 to 2012 on outpatients with HFpEF who were ran-
domized to be treated with a placebo (n = 103) or with silden-
afil (n = 113) for 24 weeks. The study was approved by the in-
stitutional review board at all participating sites, and all
participants provided informed written consent. The pri-
mary trial end point was a change in peak oxygen consump-
tion (change in oxygen consumption = 24-weekbaseline oxy-
gen consumption). Secondary end points included changes in
6-minute walk distance, a composite clinical rank score (based
on time to death and cardiovascular or cardiorenal hospital-
ization), and clinical biomarkers (creatinine, cystatin C,
N-terminal pro-B-type natriuretic peptide, and endothelin-
1). The current biomarker substudy had 160 paired plasma
samples available (79 samples from patients treated with sil-
denafil, 81 samples from patients treated with a placebo).
Metabolomic Profiling
Plasma metabolomic profiling (45 acylcarnitines, 15 amino
acids, 5 conventional) was conducted using tandem flow
injection mass spectrometry (Acquity TOD Triple Quadru-
pole; Waters) with stable-isotopelabeled internal standards3
and by conventional means3 (eMethods and eTable 1 in the
Supplement).
Statistical Analyses
Baseline patient characteristics and metabolite levels be-
tween treatment groups were compared using the Wilcoxon
rank sum test (continuous variables) and the 2/Fisher exact
test (categorical variables). An exploratory analysis of changes
in metabolite levels was first performed using the Wilcoxon
signed rank test, stratified by treatment received. A linear re-
gression model was then used with changes in metabolite re-
gressed on treatment received and adjusted for age, race/
ethnicity, sex, baseline metabolite level, and creatinine.
Correlations between changes in metabolite levels and clini-
cal biomarkers were assessed (Spearman coefficient) for the
full cohort and by treatment received. Baseline metabolite lev-
els were assessed for association with the change in oxygen
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Targeted Metabolomic Profiling in the RELAX Trial
Key Points
Question What are the underlying mechanisms and biomarkers
associated with sildenafil treatment in the PhosphodiesteRasE-5
Inhibition to Improve Clinical Status and Exercise Capacity in
Diastolic Heart Failure with Preserved Ejection Fraction (RELAX)
trial, which compared sildenafil with a placebo for treating patients
with heart failure with preserved ejection fraction?
Findings In this metabolomic profiling study using samples from
the RELAX trial, levels of circulating amino acids, short-chain
dicarboxylacylcarnitines, and long-chain acylcarnitines increased
significantly with sildenafil but not with a placebo among patients
with heart failure with preserved ejection fraction. Higher baseline
levels of short-chain dicarboxylacylcarnitine metabolite
3-hydroxyisovalerylcarnitine/malonylcarnitine and
asparagine/aspartic acid were associated with worse clinical rank
scores in groups treated with sildenafil and a placebo.
Meaning Circulating metabolites may contribute to the
underlying mechanisms associated with sildenafil and serve as
biomarkers for outcomes in heart failure with preserved ejection
fraction.
consumption, the change in 6-minute walk distance, and the
composite clinical score using multivariable linear regression
adjusted for age, sex, race/ethnicity, smoking status, the New
York Heart Association class, and the treatment received. Sen-
sitivity analyses adjusted for baseline creatinine levels were
also performed. A 2-tailed of .05 was used for statistical sig-
nificance, and the false discovery rate controlling procedure
was used to adjust for testing multiple hypotheses 4 for paired
analyses. The analyses of clinical outcomes and correlations
were unadjusted for multiple comparisons. All statistical analy-
ses were conducted using R, version 3.2 (The R Foundation).
Results
Baseline clinical characteristics and metabolite profiles did not
differ significantly between treatment groups, except for a
lower prevalence of hypertension among the group treated with
sildenafil, which was similar to results of the full trial2 (Table 1,
eTable 2 in the Supplement).
No metabolites changed significantly with treatment with
a placebo (eTable 3 in the Supplement). The levels of 7 me-
tabolites changed significantly with sildenafil treatment (false
discovery rateadjusted): alanine, proline, and lactate de-
creased; and 3 short-chain dicarboxylacylcarnitines (SCDAs)
(glutaryl carnitine, octenedioyl carnitine, and adipoyl carni-
tine) and 1 long-chain acylcarnitine (LCAC), palmitoyl carni-
tine, increased (Table 2). Consistent with the full trial,2 our
analysis also showed an association between increased clini-
cal biomarkers creatinine, cystatin C, and endothelin-1 and
sildenafil treatment (Table 2). In the multivariable regression
adjusted for age, sex, race/ethnicity, and baseline metabolite
level and creatinine, alanine and proline changes were nega-
tively associated with treatment, while changes in SCDA and
LCAC levels were positively associated (eTable 4 in the Supple-
ment). Correlations between changes in metabolites and clini-
cal biomarkers were most significant between alanine and
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 Targeted Metabolomic Profiling in the RELAX Trial Brief Report Research

Table 1. Baseline Characteristics of the Patients

All Placebo Sildenafil
Characteristic (n = 160) (n = 81) (n = 79)
Age, median (IQR), y 68 (63-76) 69 (63-76) 67 (62-75)
Women, No. (%) 81 (50.6) 46 (56.8) 35 (44.3)
White, No. (%) 148 (92.5) 75 (92.6) 73 (92.4)
BMI, median (IQR) 32.9 (28.4-38.4) 32.7 (28.6-37.1) 33.0 (28.3-38.9)
NYHA, No. (%)
2 77 (48.1) 39 (48.2) 38 (48.1)
3 83 (51.9) 42 (51.9) 41 (51.9)
Qualifying EF, % (IQR) 61 (56-66) 60 (55-65) 60 (57-66)
Medical history, No. (%)
Hypertension 135 (84.4) 74 (91.4) 61 (77.2)
Arrhythmia 78 (48.8) 38 (46.9) 40 (50.6)
Diabetes 66 (41.3) 33 (40.7) 33 (41.8)
COPD 29 (18.1) 18 (22.2) 11 (13.9)
Hyperlipidemia 119 (74.4) 65 (80.3) 54 (68.4) Abbreviations: BMI, body mass index
(calculated as weight in kilograms
Creatinine, median (IQR), mg/dL 1.1 (0.8-1.3) 1.1 (0.9-1.3) 1.1 (0.8-1.3)
divided by height in meters squared);
Peak functional status, median (IQR) COPD, chronic obstructive pulmonary
Oxygen consumption, mL/kg/min 11.7 (10.4-14.7) 11.9 (10.2-14.3) 11.6 (10.5-15.4) disease; EF, ejection fraction;
IQR, interquartile range; NYHA, New
6-min walk distance, m 327 (253-388) 326 (251-380) 328 (262-400)
York Heart Association.

lactate (Spearman rank correlation coefficient, 0.52;
P = 1.1 1010); SCDA levels (glutaryl carnitine, methylmalo-
nyl carnitine/succinyl carnitine, 3-hydroxyisovalerylcartine/
malonylcarnitine, octenedioyl carnitine, 3-hydroxy-cis-5-
octenoyl carnitine) and creatinine/cystatin C, and LCACs and
endothelin-1 (eFigure and eTable 5 in the Supplement).
Similar to the full trial, our analyses did not reveal any dif-
ference in the primary (the change in oxygen consumption) or
secondary end points (the change in 6-minute walk distance
and composite clinical score) between treatment groups
(P = .80, .98, and .75, respectively). Higher levels of 7 base-
line metabolites were associated with worse clinical scores:
SCDA 3-hydroxyisovalerylcartine/malonyl carnitine, methyl-
malonyl carnitine/succinyl carnitine, and glutaryl carnitine
(, 96.60, 50.24, and 31.35, respectively; P = .001, .02, and
.03, respectively); short-chain acylcarnitines butyryl carnitine/
isobutyryl carnitineand tigyl carnitine (, 5.60 and 85.59;
P = .02); and amino acids asparagine/aspartic acid and citrul-
line (, 0.02 and 0.08; P = .01 and .03, respectively) (Table 3).
After adjusting for baseline creatinine, asparagine/aspartic acid
remained significantly associated with the clinical score
(P = .02), while 3-hydroxyisovalerylcartine/malonylcarni-
tine showed a trend toward association (P = .09).
Discussion
Using targeted metabolomic profiling in paired samples from
the RELAX trial, we found circulating metabolites among pa-
tients with HFpEF that were modified by treatment with sil-
denafil: decreased alanine and proline, and increased LCACs
and SCDAs. The increases in LCAC and SCDA metabolites cor-
related with worsening collagen metabolism biomarkers (en-
dothelin-1) and renal function (creatinine and cystatin C) bio-
markers, respectively. Additionally, baseline levels of the SCDA
metabolite 3-hydroxyisovalerylcartine/malonylcarnitine and
asparagine/aspartic acid were associated with a worse com-
posite clinical rank score at 24 weeks.
Long-chain acylcarnitine metabolites have been impli-
cated in mitochondria-mediated inflammation and cellular
stress promotion. In this study, LCAC metabolite levels in-
creased with sildenafil treatment and exhibited a significant
correlation with endothelin-1, an established prognostic bio-
marker for mortality and morbidity in heart failure.5 While the
exact mechanism of sildenafil-associated elevation in LCAC
metabolites is unclear, our findings suggest that the role of
mitochondrial dysfunction and alterations in the endothe-
lin-1 signaling pathway are potential explanations.
The accumulation of SCDA metabolites reports on dys-
regulated endoplasmic reticulum stress of the ubiquitin-
proteasome system, which induces an autophagy to remove
damaged cells.6,7 In this study, increased SCDAs by sildenafil
treatment may be explained by this pathway activating, which
could lead to a disrupted cellular homeostasis, dysregulated
autophagy, and worse long-term outcomes. This negative con-
sequence may have contributed to the lack of benefits re-
ceived by those treated with sildenafil therapy.
In this study, higher baseline levels of the SCDA 3-hydroxy-
isovalerylcartine/malonylcarnitine and amino acids aspara-
gine/aspartic acid were associated with worse clinical scores.
The SCDA result is consistent with previous studies that dem-
onstrated an association between SCDA metabolites and car-
diovascular events.8,9 Notably, this association was attenu-
ated after adjusting for baseline renal function, which could
be because of an impaired clearance of SCDAs with impaired
renal function or an underlying pathophysiology affecting re-
nal function and SCDA metabolism concordantly. In prior stud-
ies, SCDAs were associated with incident cardiovascular events

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 Research Brief Report Targeted Metabolomic Profiling in the RELAX Trial

Table 2. Changes in Metabolite Levels After 24 Weeks With Sildenafil Treatment

P Value
Class Metabolitea Baseline, Median Change, Median (25th-75th) Nominalb FDR-Adjusted
Amino acids, m GLY 296.6 3.38 (23.82 to 24.27) .55 .69
ALA 429.45 38.36 (100.3 to 28.19) <.001 .01
SER 93.27 1.28 (8.36 to 11.01) .68 .77
PRO 243.42 28.24 (56.29 to 12.03) .002 .03
VAL 240.77 11.9 (33.28 to 10.52) .01 .08
LEU/ILE 157.79 6.44 (25.08 to 12.19) .09 .23
MET 27.06 0.15 (4.64 to 2.54) .43 .61
HIS 33.96 1.09 (3.61 to 2.59) .25 .43
PHE 66.58 0.4 (7.53 to 5.89) .58 .69
TYR 75.4 0.61 (9.93 to 4.97) .52 .67
ASX 57.3 0.01 (14.37 to 18.64) .93 .96
GLX 129.51 0.67 (12.43 to 22.81) .59 .69
ORN 93.55 1.97 (14.9 to 22.14) .46 .63
CIT 42.18 0.37 (5.03 to 9.21) .39 .58
ARG 68.63 2.98 (10.45 to 17.11) .11 .25
Acylcarnitines, nm C2 9762.22 52.45 (1251.95 to 1474.17) .79 .87
C3 456.39 9.12 (91.88 to 94.45) .92 .96
C4/CI4 284 1.35 (45.13 to 47.33) .62 .72
C5:1 44.03 1.97 (2.71 to 8.24) .03 .13
C5 177.89 0.73 (38.83 to 41.49) .89 .95
C4-OH 39.81 0.41 (12.16 to 13.19) .98 .98
C5-OH/C3-DC 39.28 2.03 (3.47 to 7.45) .06 .20
C4-DC/Ci4-DC 58.95 1.27 (7.72 to 10.76) .28 .43
C8:1 368.43 11.11 (58.3 to 102.13) .29 .43
C8 133.85 10.87 (38.31 to 63.18) .08 .21
C5-DC 58.63 6.19 (3.37 to 14.18) <.001 .01
C8:1-OH/C6:1-DC 41.05 3.72 (5.42 to 11.25) .04 .14
C6-DC/C8-OH 100.41 10.72 (11.23 to 29.57) .01 .05
C10:3 113.91 8.99 (12.6 to 35.17) .06 .19
C10:2 37.42 1.54 (8.54 to 11.59) .24 .43
C10:1 177.62 17.72 (38.05 to 77.64) .05 .18
C10 216.12 32.78 (53.07 to 124.16) .04 .14
C8:1-DC 34.98 2.72 (3 to 12.57) .004 .04
C10-OH/C8-DC 46.99 4.49 (10.55 to 19.87) .07 .20
C12: 1 103.86 8.29 (24.05 to 47.32) .10 .25
C12 73.95 9.54 (12.26 to 34.21) .03 .13
C12-OH/C10-DC 16.11 0.72 (2.52 to 6.94) .07 .21
C14: 2 42.79 5.37 (12.52 to 28.01) .10 .25
C14: 1 69.79 8.45 (20.34 to 38.72) .14 .28
C14 33.8 1.65 (7.68 to 9.57) .27 .43
C14: 1-OH 16.51 1.1 (3.6 to 6.11) .14 .28
C14-OH/C12-DC 9.31 0.9 (1.55 to 3.14) .06 .20
C16: 2 10.14 0.83 (2.58 to 4.2) .18 .34
C16: 1 27.66 2.78 (7.31 to 12.06) .16 .32
C16 92.85 7.83 (5.64 to 26.99) .002 .03
C16:1-OH/C14:1-DC 8.12 0.5 (1.58 to 2.99) .14 .28
C16-OH/C14-DC 6.3 0.83 (0.82 to 2.47) .01 .07
C18:2 74.9 8.22 (11.73 to 28.85) .11 .25
C18:1 123.11 6.47 (25.49 to 44.96) .18 .33
C18 42.55 1.29 (5.95 to 8.88) .42 .61

(continued)

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 Targeted Metabolomic Profiling in the RELAX Trial Brief Report Research

Table 2. Changes in Metabolite Levels After 24 Weeks With Sildenafil Treatment (continued)

P Value
Class Metabolitea Baseline, Median Change, Median (25th-75th) Nominalb FDR-Adjusted
C18:2-OH 4.89 0 (0.97 to 1.49) .53 .68
C18:1-OH/C16:1-DC 5.42 0.65 (0.75 to 2.36) .01 .08
C18-OH/C16-DC 7.26 0.81 (0.99 to 2.91) .02 .13
C20:4 7.07 0.32 (1.39 to 1.91) .58 .69
C20 4.04 0.16 (1.33 to 1.31) .47 .63
C18:1-DC 10.12 1.15 (0.98 to 3.32) .01 .07
C20-OH/C18-DC 11 0.65 (1.15 to 3.36) .03 .13
C22 2.75 0 (1.31 to 1.24) .86 .94
Conventional Glucose (mg/dL) 105 2 (17.5 to 19) .49 .66
NEFA (mmol/L) 0.36 0.08 (0.27 to 0.21) .66 .75
Total ketones (mol/L) 66.7 3.1 (53.1 to 28.2) .26 .43
3-OH butyrate (mol/L) 42.2 1.2 (36.75 to 17.1) .21 .37
Lactate (mmol/L) 2.0 0.3 (0.85 to 0.1) .001 .02
Creatinine 1.08 0.05 (0.02 to 0.14) .004 .23
Cystatin C 1.20 0.05 (0.03 to 0.16) .03 .07
Endothelin-1 2.21 0.44 (0.12 to 0.98) 2.8 107 2.5 105

Abbreviation: FDR, false discovery rate.

a
Metabolite abbreviations are included in eTable 1 in the Supplement.
b
P value from Wilcoxon signed-rank tests.

Table 3. Multiple Linear Regression for Metabolite Association With Composite Clinical Rank Score Adjusted
for Age, Sex, Race/Ethnicity, Smoking Status, New York Heart Association Class, and Treatment Groups
(Slope)
Class Metabolite Estimate P Value
SCDA/SC acylcarnitines C5-OH/C3-DCa,b 96.60 .001
b
C8:1-DC 59.43 .02 Abbreviations: SC, short-chain;
C4/Ci4b 5.60 .02 SCDA, short-chain dicarboxyl.
a
C5:1b 85.59 .02 Denotes metabolites that remained
b
significant (C5-OH/C3-DC, P = .04;
C4-DC/Ci4-DC 50.24 .02 asparagine/aspartic acid, P = .05)
C5-DCb 31.35 .03 after adjusting for all other
Amino acid Asparagine/aspartic acida 0.02 .01 metabolites.
b
Abbreviation included in eTable 1 in
Citrulline 0.08 .03
the Supplement.

even after adjusting for baseline estimated glomerular filtra-
tion rates,10 suggesting that a complex relationship exists be-
tween SCDAs, renal function, and cardiovascular disease. The
amino acid result is consistent with recent studies showing
higher levels of asparagine/aspartic acid in HFpEF compared
with patients who had not experienced heart failure,11 high-
lighting the importance of underlying alterations in amino acid
metabolism in HFpEF. The internal standards used to quan-
tify asparagine/aspartic acid do not discriminate these 2 me-
tabolites, and thus we were unable to determine the specific
biologic pathway represented.
Limitations
This study has several limitations. Patients were selected who
could perform the peak oxygen consumption test, which may
have introduced biases. Additionally, our results of metabo-
lite association with clinical end points were attenuated when
adjusting for baseline renal function, suggesting that a com-
plex relationship exists between SCDAs, renal function, and
cardiovascular disease.
Conclusions
Among patients with HFpEF, phosphodiesterase type 5 inhi-
bition with sildenafil treatment resulted in significantly
increased LCAC and SCDA metabolites that paralleled in-
creases in adverse clinical markers. These results suggest that
there is a potential role of mitochondrial dysfunction and en-
doplasmic reticulum stress among patients with HFpEF who
are treated with sildenafil and provide potential candidates for
biomarkers associated with clinical outcomes.

ARTICLE INFORMATION Published Online: May 10, 2017. Author Contributions: Drs Wang and Shah had full
Accepted for Publication: March 17, 2017. doi:10.1001/jamacardio.2017.1239 access to all the data in the study and take

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 Research Brief Report
responsibility for the integrity of the data and the
accuracy of the data analysis.
Concept and design: Wang, Bain, Hernandez, Felker,
Redfield, Shah.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Wang.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Wang, Anstrom, Shah.
Obtained funding: Hernandez, Shah.
Administrative, technical, or material support:
Newgard, Hernandez, Shah.
Supervision: Newgard, Felker, Shah.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest.
Dr Newgard is a member of the Pfizer CVMED
scientific advisory board. Dr Hernandez reports
receiving consultant fees/honoraria from BMS,
Boston Scientific, Gilead, Janssen, and Novartis.
Dr Felker reports receiving consultant fees/
honoraria from Amgen, Novartis, Trevena, Singulex,
and Medtronic. Dr Redfield reports receiving
royalties from Annexon. Dr Shah reports holding a
patent on a related finding. No other disclosures
were reported.
Funding/Support: Funding support was provided
by grants HL127009 and T32HL007101 (principal
investigator [PI], Dr Shah) from the National
Institutes of Health and the American Heart
Association Strategically Focused Research
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Network Heart Failure Grant (PIs, Drs Shah, Felker,
and Hernandez).
Role of the Funder/Sponsor: The funders had no
role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
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