From the Guidelines
Sildenafil can be used in patients with a history of myocardial infarction (MI), but with caution and careful assessment of cardiac risk, as it may increase the risk of MI, especially when combined with nitrate medications. The primary concern is the potential for dangerous drops in blood pressure, especially when combined with nitrate medications, which is an absolute contraindication 1. Patients taking nitrates for angina should never use sildenafil as this combination can cause severe hypotension, potentially leading to cardiovascular collapse. For post-MI patients not on nitrates, sildenafil may still cause modest blood pressure reductions (typically 8-10 mmHg systolic), which most stable cardiac patients can tolerate. Other cardiovascular risks include increased heart rate, arrhythmias, and rare reports of MI or sudden cardiac death temporally associated with sildenafil use, though causality is difficult to establish 1.
Key Considerations
- Patients with a history of MI should be stable for at least 6 months before considering sildenafil use
- Cardiac risk assessment is crucial before prescribing sildenafil to post-MI patients
- Exercise tolerance should be evaluated, and patients should be able to perform moderate physical activity without symptoms
- The lowest effective dose of sildenafil (25mg) should be used, and patients should be educated about potential warning signs requiring immediate medical attention, including chest pain, severe dizziness, or fainting during sexual activity 1
- Sexual activity should be deferred until the cardiac condition has been stabilized and sexual activity can be safely resumed, especially in high-risk patients
Management Approach
- A collaborative approach to managing men's sexual function and cardiovascular risk is recommended, incorporating general, urologic, endocrine, and cardiologic expertise 1
- Treatment for ED should not negatively affect cardiovascular health, and potential effects on erectile function of agents used to treat cardiovascular risk factors should be considered
- Patient follow-up and reassessment is recommended to ensure safe and effective use of sildenafil in post-MI patients.
From the FDA Drug Label
Cardiovascular Events In postmarketing experience with sildenafil at doses indicated for erectile dysfunction, serious cardiovascular, cerebrovascular, and vascular events, including myocardial infarction, sudden cardiac death, ventricular arrhythmia, cerebrovascular hemorrhage, transient ischemic attack, hypertension, pulmonary hemorrhage, and subarachnoid and intracerebral hemorrhages have been reported in temporal association with the use of the drug. Sildenafil can cause myocardial infarction (MI), as it has been reported in postmarketing experience with the drug, often in patients with preexisting cardiovascular risk factors.
- The relationship between sildenafil and MI is not fully understood, and it is unclear whether the events are directly related to the drug, sexual activity, or underlying cardiovascular disease 2.
From the Research
Cardiovascular Risks Associated with Sildenafil
The use of sildenafil (Viagra) in patients with a history of myocardial infarction (MI) has been studied in various clinical trials and research papers.
- The primary concern is the potential for sildenafil to cause a synergistic and major decrease in systemic arterial pressure when combined with organic nitrates, which is contraindicated in patients taking these medications 3, 4, 5, 6.
- Studies have shown that sildenafil is effective and not associated with an increase in serious cardiovascular adverse events, myocardial infarction (MI), or death compared with placebo in patients with erectile dysfunction and cardiovascular disease 3, 4, 5, 6.
- However, there is a small but finite increased risk of developing ischemia or infarction with sexual activity, and physicians should discuss the potential cardiac risk of sexual activity with patients before prescribing sildenafil 3, 4, 5.
- Sildenafil should be used with caution in patients who take alpha-blockers, as coadministration may lead to symptomatic hypotension in some individuals 5.
- The overall conclusion is that sildenafil is a safe drug and that its appropriate use does not seem to increase the risk for myocardial infarction or sudden cardiac death 7.
Key Findings
- Sildenafil does not cause major decreases in blood pressure when administered with one or more standard antihypertensive agents 3.
- Sildenafil is mildly vasodilating in the coronary circulation and does not increase the risk of ventricular arrhythmia 5.
- Clinical trial data and observational studies have shown that sildenafil is not associated with an increased risk of serious cardiovascular events, including myocardial infarction and death 4, 5, 6.
- Sildenafil may have a cardioprotective effect and does not reduce exercise tolerance in men with known coronary artery disease 7.