Can you take tadalafil (phosphodiesterase type 5 inhibitor) after a myocardial infarction (heart attack)?

Can You Take Tadalafil After a Heart Attack?

Tadalafil can be used after a myocardial infarction, but only after a minimum waiting period of 90 days and with careful cardiovascular assessment, provided the patient is not taking nitrates and does not have other high-risk cardiac conditions. 1

Critical Absolute Contraindications

The most important safety consideration is the absolute contraindication between tadalafil and nitrate therapy:

• Patients must wait at least 48 hours after taking tadalafil before any nitrate can be administered due to the risk of profound hypotension, myocardial infarction, and death 2, 3, 4
• This interaction occurs because tadalafil inhibits phosphodiesterase-5, which degrades cyclic guanosine monophosphate (cGMP), and when combined with nitrates causes markedly exaggerated and prolonged vasodilation 3, 4
• The FDA label explicitly states that in patients requiring emergency nitrate therapy after tadalafil use, at least 48 hours must have elapsed since the last tadalafil dose 1

Timing After Myocardial Infarction

The FDA label specifically excludes patients with myocardial infarction within the last 90 days from tadalafil use 1:

• Tadalafil is not recommended until at least 3 months have passed since the acute event 1
• This waiting period allows for cardiac stabilization and assessment of residual ventricular function 1

Additional High-Risk Cardiac Exclusions

Even after 90 days, tadalafil remains contraindicated in patients with: 1

• Unstable angina or angina occurring during sexual intercourse 1
• New York Heart Association Class 2 or greater heart failure within the last 6 months 1
• Uncontrolled arrhythmias 1
• Hypotension (blood pressure <90/50 mm Hg) or uncontrolled hypertension 1
• Stroke within the last 6 months 1

Cardiovascular Assessment Required

Before prescribing tadalafil to post-MI patients, physicians must: 1

• Evaluate whether the patient's cardiovascular status makes sexual activity inadvisable, as there is inherent cardiac risk with sexual activity 1
• Consider that tadalafil has mild systemic vasodilatory properties causing transient blood pressure decreases (mean maximal decrease of 1.6/0.8 mm Hg in healthy subjects) 1
• Assess for left ventricular outflow obstruction (e.g., aortic stenosis), as these patients are particularly sensitive to vasodilators 1

Safety Data in Coronary Artery Disease

The available evidence suggests reasonable safety when used appropriately: 5, 6

• A retrospective analysis of 12,487 men with erectile dysfunction (5% with coronary artery disease at baseline) showed the incidence rate of serious cardiovascular events was 0.40/100 patient-years with tadalafil versus 0.43/100 patient-years with placebo 5
• The myocardial infarction rate in tadalafil-treated patients (0.43 per 100 patient-years) was actually lower than placebo (0.6 per 100 patient-years) and comparable to the age-standardized male population 6
• Studies in patients with stable coronary artery disease showed tadalafil had no adverse effects on myocardial blood flow and may even augment flow during increased cardiac workload 7

Critical Clinical Pitfalls to Avoid

The most dangerous scenario is a post-MI patient on chronic nitrate therapy who takes tadalafil: 3, 4

• Patients taking long-acting nitrates (such as isosorbide mononitrate) should never use tadalafil 4
• If erectile dysfunction treatment is desired, consider transitioning from nitrate therapy to alternative antianginal agents (beta-blockers, calcium channel blockers, or ranolazine) if clinically appropriate 4
• The American College of Cardiology emphasizes this is a Class III recommendation (harm), meaning the intervention should not be performed 3

Patient Counseling Essential Points

Patients must be instructed to: 1

• Stop sexual activity immediately and seek emergency care if they experience chest pain, dizziness, or nausea during sex 1
• Understand that if they develop anginal chest pain requiring nitroglycerin after taking tadalafil, they must inform emergency personnel that at least 48 hours must elapse before nitrate administration 1
• Recognize that sexual activity itself places extra strain on the heart, particularly if the heart is already weakened from a previous heart attack 1

Post-MI Medication Considerations

The European Society of Cardiology guidelines emphasize that post-MI patients should be on: 2

• Beta-blockers indefinitely (reduce mortality and reinfarction by 20-25%) 2
• ACE inhibitors for those with reduced ejection fraction (<40%) or heart failure 2
• These medications do not contraindicate tadalafil use but must be considered when evaluating overall cardiovascular status 1