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[Sildenafil, the heart patient and the cardiologist]
1Service de cardiologie, CHU Nancy-Brabois, Vandoeuvre-lès-Nancy.
Insights
Sildenafil (Viagra) is safe for most patients, but dangerous when combined with nitrates due to severe blood pressure drops. Assess coronary risk before prescribing sildenafil for erectile dysfunction.
Area of Science:
- Pharmacology
- Cardiology
- Urology
Context:
- Sildenafil (Viagra), a phosphodiesterase-5 inhibitor, is widely used for erectile dysfunction.
- Its vasodilatory effects necessitate a thorough coronary risk evaluation before prescription.
- Understanding the risks associated with both the drug and sexual activity is crucial.
Purpose:
- To evaluate the cardiovascular risks associated with sildenafil (Viagra) prescription.
- To determine if sildenafil use or the return to sexual activity poses special risks.
- To provide guidance on safe sildenafil use in patients with and without coronary artery disease.
Summary:
- Sildenafil causes a mild decrease in blood pressure, not significantly worsened by antihypertensives.
- Co-administration with nitrate derivatives is strictly contraindicated due to dangerous blood pressure reduction.
- Clinical trials show sildenafil is safe, with no increased risk of myocardial infarction; sexual activity poses minimal cardiac risk.
Impact:
- Clinicians should assess coronary risk, especially in patients with known heart conditions.
- Sildenafil is contraindicated in unstable cardiac situations and requires caution in stable coronary disease.
- Patients must be explicitly warned against combining sildenafil with nitrate derivatives.
Abstract:
Sildenafil (Viagra), an inhibitor of phosphodiesterase 5, has a powerful vasodilatory effect on the corpus cavernosa. An evaluation of coronary risk is necessary before its prescription in order to answer two questions: does taking this drug expose the patient to any special risk? Does the return to sexual activity itself carry any risk? Sildenafil is associated with a slight decrease in systolic (10 mmHg) and diastolic (7 mmHg) blood pressure which does not seem to be accentuated by the concommittant use of antihypertensive drugs. The co-administration of nitrate derivatives (before or after taking sildenafil) causes potentially dangerous falls in blood pressure (on average 40 mmHg for the systolic blood pressure). Co-administration of sildenafil and NO-donors is formally contra-indicated. The safety of sildenafil has been shown to be satisfactory in clinical trials: in particular, the risk of myocardial infarction is no greater in treated patients. Sexual activity is a generally moderately intense physical exercise and only rarely causes myocardial infarction. In practice, in patients without known coronary artery disease, the clinical history should be sufficient to determine whether the return of sexual relations is possible without risk. In known cardiac patients, sildenafil is contra-indicated in unstable situations; in stable coronary disease, it would seem wise to take advantage of the annual exercise stress testing to make sure of the absence of ischaemia on effort. In all cases, the patient must be warned that co-administration of nitrate derivatives is an absolure contra-indication to sildenafil treatment.