Compared with riociguat therapy, balloon pulmonary angioplasty (BPA) may be associated with greater improvements in exercise tolerance and pulmonary hemodynamics, with the exception of cardiac index and cardiac output, according to a study published in Clinical Cardiology. Overall, both therapies were well tolerated, but findings should be confirmed by additional studies.

This meta-analysis compared the safety and efficacy of BPA with riociguat therapy in patients with inoperable chronic thromboembolic pulmonary hypertension. Searches in the, Embase, and PubMed databases found 23 clinical trials of these treatments, with a total 1454 participants (BPA; n=631 and riociguat; n=823). The Newcastle-Ottawa Scale for the assessment of nonrandomized study quality in meta-analyses was used to assess risk for bias.

When compared with riociguat therapy, BPA was associated with greater improvements in right atrial pressure (mean difference [MD], -3.53 mm Hg [95% CI, -4.85 to -2.21 mm Hg] vs MD, -1.05 mm Hg [95% CI, -1.82 to -0.29 mm Hg]), mean pulmonary artery pressure (MD, -15.02 mm Hg [95% CI, -17.32 to −12.71 mm Hg] vs MD, -4.19 mm Hg [95% CI, -5.58 to -2.80 mm Hg]), pulmonary vascular resistance (standard MD, -1.32 Woods [95% CI, -1.57 to -1.08 Woods] vs standard MD, -0.65 Woods [95% CI, -0.79 to -0.50 Woods]), New York Heart Association functional class (RR, 6.78 [95% CI, 3.14-14.64] vs RR, 1.49 [95% CI, 1.07-2.07]), and 6-minute walk test distance (MD, 71.66 m [95% CI, 58.34-84.99 m] vs MD, 45.25 m [95% CI, 36.51-53.99 m]).

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However, the increase in cardiac output was greater with riociguat than with BPA (MD, 0.78 L/min [95% CI, 0.61-0.96 L/min] vs MD, 0.33 L/min [95% CI, 0.06-0.59 L/min]), and there was no significant difference in cardiac index between BPA and riociguat (MD, 0.40 L/min/m2 [95% CI, 0.21-0.58 L/min/m2] vs MD, 0.40 L/min/m2 [95% CI, 0.26-0.54 L/min/m2]).

The most common BPA complications were pulmonary edema (0.8%-28.6%) and pulmonary injury (0.3%-5.6%), and the most common riociguat adverse events were dizziness, headache, hypotension, and nasopharyngitis.

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The study investigators concluded, “Overall, both BPA and riociguat were well tolerated. However, our findings need to be confirmed with further multicenter randomized control trials…and prospective observational studies.”


Wang W, Wen L, Song Z, Shi W, Wang K, Huang W. Balloon pulmonary angioplasty vs riociguat in patients with inoperable chronic thromboembolic pulmonary hypertension: a systematic review and meta-analysis [published online June 12, 2019]. Clin Cardiol. doi:10.1002/clc.23212