From the Guidelines
Viagra (sildenafil) can pose significant cardiac risks, particularly for individuals with pre-existing heart conditions, and should be used with caution under medical guidance. The medication works by relaxing blood vessels, which can lower blood pressure by 5-8 mmHg, and its use is contraindicated in patients taking nitrate medications for chest pain due to the risk of dangerous drops in blood pressure 1. People with recent heart attacks, strokes, unstable angina, severe heart failure, or uncontrolled high or low blood pressure should not use Viagra without medical clearance.
Key Considerations
- A thorough cardiac evaluation is recommended before starting treatment with sildenafil to assess the risk of cardiovascular events 1.
- Common cardiovascular side effects of sildenafil include headache, flushing, and mild blood pressure changes.
- Anyone experiencing chest pain, severe dizziness, or fainting while using Viagra should seek immediate medical attention.
- The standard starting dose is 50mg taken approximately one hour before sexual activity, but this may be adjusted based on individual health factors.
High-Risk Patients
Patients with high-risk cardiac conditions, such as unstable angina or severe heart failure, should be referred to a cardiologist for further evaluation and managed with a collaborative approach to primary prevention 1. In these cases, sexual activity should be deferred until the cardiac condition has been stabilized and sexual activity can be safely resumed.
Guidance and Recommendations
Always consult with a healthcare provider about potential heart risks before using Viagra, especially if you have any existing cardiovascular conditions. The use of sildenafil should be considered secondary to maintaining cardiovascular function, and treatment for erectile dysfunction should not negatively affect cardiovascular health 1.
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.
Most, but not all, of these patients had preexisting cardiovascular risk factors. Many of these events were reported to occur during or shortly after sexual activity, and a few were reported to occur shortly after the use of sildenafil without sexual activity Others were reported to have occurred hours to days after use concurrent with sexual activity.
It is not possible to determine whether these events are related directly to sildenafil, to sexual activity, to the patient's underlying cardiovascular disease, or to a combination of these or other factors.
The cardiac risks associated with sildenafil (Viagra) include:
- Myocardial infarction
- Sudden cardiac death
- Ventricular arrhythmia These events have been reported in temporal association with the use of the drug, often in patients with preexisting cardiovascular risk factors 2.
From the Research
Cardiac Risks Associated with Sildenafil (Viagra)
The cardiac risks associated with sildenafil (Viagra) are a concern due to the potential for interactions with the cardiovascular system.
- Sildenafil can cause a mild decrease in systemic arterial pressure, which can be synergistic and often major in the presence of organic nitrates (nitric oxide donors) 3, 4, 5, 6.
- The use of nitrates is contraindicated with sildenafil due to the risk of severe hypotension 3, 4, 5, 6.
- Sildenafil is also contraindicated in patients with severe aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM), and those taking long-acting nitrates 3, 6.
- Caution is necessary when prescribing sildenafil to patients with certain cardiovascular conditions, such as coronary artery disease, liver or kidney disease, and those taking medications that may prolong sildenafil's half-life 3, 4, 6.
- The risk of myocardial infarction or death is not increased with sildenafil use, but physicians should discuss the risks of sexual activity with their cardiac patients before prescribing any treatment for ED 7, 5, 6.
- Exercise treadmill testing may be warranted to determine whether ED patients with coronary artery disease can achieve the physiologic workload associated with sexual intercourse 3, 5.
Recommendations for Sildenafil Use
- Physicians should carefully consider whether their patients with underlying cardiovascular disease could be affected adversely by resuming sexual activity 6.
- Management recommendations based on cardiovascular risk, from the Second Princeton Consensus Conference, should be followed 6.
- Sildenafil should be used with caution in patients who take alpha-blockers, and patients should be stable on alpha-blocker therapy before initiating sildenafil treatment 6.
- The adverse event profile of sildenafil is similar overall to that in men with comorbid cardiovascular disease, and it is similar between those with and without coronary artery disease 6.