Most men with heart disease can take sildenafil safely

Viagra (sildenafil) has revolutionized the treatment of male sexual
dysfunction. However, its use has been said to be dangerous in patients with
certain types of heart disease. The purpose of this article is to review the
safe use of sildenafil in men with heart disease.

Sildenafil has two actions that may be of consequence in patients with heart
disease. First, it can lower the blood pressure. Second, it interacts with
nitrates.

Sildenafil is a vasodilator (that is, a drug that dilates blood vessels), and
consequently it lowers the systolic blood pressure (the "top" number in blood
pressure measurements) by an average of 8 mmHg. In the majority of patients
with heart disease, including most of those being treated with
antihypertensive drugs, this is not a problem. Studies have shown that the
incidence of side effects (including side effects related to low blood
pressure, such as dizziness and fainting) are no higher in users of
sildenafil who are also taking antihypertensive drugs.

However, the vasodilating effects of sildenafil do become potentially
hazardous when combined with the vasodilating effects of nitrates, drugs that
are still commonly used in patients with coronary artery disease. Patients
taking both nitrates and sildenafil are prone to develop severe hypotension
(low blood pressure) and syncope (fainting.) Patients taking nitrates for
their coronary artery disease, therefore, should never take sildenafil.
Further, anyone who has taken sildenafil during the past 24 hours should not
take nitrates.

When sildenafil was first introduced in the late 1990s, reports of heart
attack and sudden death after taking the drug appeared all over the news.
Subsequent studies have suggested that, in patients not taking nitrates, the
use of sildenafil in patients with stable coronary artery disease does not
cause an increased risk of heart attack or death. While these events indeed
occur in patients with coronary artery disease, their incidence is no higher
in patients taking sildenafil.

Indeed, sildenafil appears to be quite well tolerated in men with even severe
coronary artery disease, as long as they do not have active ischemia (periods
of time where the heart muscle is not getting appropriate blood flow, most
often manifested by chest pain) and are not taking nitrates. Further,
sildenafil does not increase the risk of exercise in patients with stable
coronary artery disease.

There are some conditions in which the modest drop in systolic blood pressure
caused by sildenafil may be dangerous. Patients with severe heart failure
accompanied by low blood pressure measurements may become worse if further
hypotension is produced. In addition, some patients with hypertrophic
cardiomyopathy may become symptomatic if their systolic blood pressure is
reduced.

The bottom line

The American College of Cardiology and the American Heart Association concur
that sildenafil is safe for men with stable coronary artery disease who are
not taking nitrates, but should never be used in patients who are taking
nitrates. (Nitrates include all forms of nitroglycerin - sublingual,
transdermal and spray forms - as well as isosorbide mononitrate, isosorbide
dinitrate, pentaerythritol tetranitrate, erythrityl tetranitrate, and amyl
nitrate.)

It should be noted that, while in the past nitrates were the foundation of
therapy for coronary artery disease, this is no longer the case. In the era
of angioplasty and stenting, coronary artery disease is usually manageable
without resorting to nitrates. Patients who are being prescribed nitrates and
wish to take sildenafil should ask your doctors about alternate forms of
therapy for their coronary artery disease.

There are other groups of heart patients for whom sildenafil may be
potentially dangerous. These include patients with unstable coronary artery
disease or active coronary artery ischemia (i.e., patients whose coronary
artery disease is not stable.) These patients, obviously, have an active
medical problem that needs to be stabilized whether or not sildenafil is
being considered. Once they are sufficiently treated, the use of sildenafil
(as well as all other forms of routine, daily life such as exercise) can be
entertained.

Other patients who may have trouble with sildenafil are those with heart
failure accompanied by borderline low blood pressure, some patients with
hypertrophic cardiomyopathy, and possibly, patients on complicated drug
regimens for hypertension.

With these exceptions, sildenafil can be used safely in the vast majority of
patients with heart disease.

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