Can you take Viagra (sildenafil) after a stroke?

Can You Take Viagra After a Stroke?

Yes, sexual activity and Viagra (sildenafil) are not contraindicated after stroke, but patients with a history of stroke may be at increased risk of hemodynamic impairment and require careful cardiovascular risk assessment before prescribing. 1, 2

Key Safety Principle

The most important message from stroke rehabilitation guidelines is that sexual activity is not contraindicated after stroke 1. However, this does not mean PDE5 inhibitors like Viagra are automatically safe for all stroke survivors.

Critical Contraindications (Absolute)

Before prescribing Viagra after stroke, you must rule out:

• Nitrate use in any form (nitroglycerin, isosorbide) - this is an absolute contraindication due to risk of potentially fatal hypotension 1, 3, 4
• Wait 24 hours after sildenafil use before giving nitrates if emergency nitrate administration becomes necessary 3
• Tadalafil requires 48 hours before nitrate administration 1
• Hypotension (systolic BP <90 mmHg or >30 mmHg below baseline) 1

Stroke-Specific Concerns

Evidence of Hemodynamic Risk

Patients with prior stroke showed significantly more areas of diminished cerebral perfusion after sildenafil administration compared to baseline on SPECT imaging, unlike patients with only diabetes or hypertension 2. This suggests stroke survivors may be uniquely vulnerable to sildenafil's hemodynamic effects.

Cardiovascular Risk Stratification Required

Before prescribing Viagra to a stroke survivor, assess their cardiovascular risk 3:

• Low-risk patients (asymptomatic CAD with <3 risk factors, controlled hypertension, mild stable angina, successful revascularization, uncomplicated past MI, mild valvular disease, CHF NYHA class I) can safely receive PDE5 inhibitors 3
• Indeterminate risk patients or those unable to perform moderate physical activity should be referred to cardiology before prescribing 3

Timing After Stroke

• The 2005 stroke rehabilitation guideline recommends discussing sexual issues during rehabilitation and again after community transition when the patient and partner are ready 1
• Research shows sildenafil 25 mg daily started 2-9 days after stroke appeared safe in a small safety study, though one sudden death occurred 5
• Animal studies suggest potential neurorestorative benefits when sildenafil is given 2-24 hours or even 1 week post-stroke, with enhanced neurogenesis and functional recovery 6, 7

Practical Prescribing Algorithm

1. Screen for absolute contraindications: nitrate use, severe hypotension 1
2. Assess cardiovascular risk: Can the patient perform moderate physical activity? 3
3. If indeterminate risk: Refer to cardiology before prescribing 3
4. If low risk: Start with lowest effective dose (sildenafil 50 mg as needed, or tadalafil 10 mg) 3
5. Ensure adequate trial: At least 5 separate attempts at maximum dose before declaring treatment failure 3
6. Monitor for adverse effects: headache, flushing, dyspepsia, back pain (tadalafil), and most importantly, hypotension 3

Important Caveats

• One case report documented bilateral MCA infarction after 100 mg sildenafil use, with persistent systemic hypotension despite significant bilateral MCA stenosis 8
• Patients over 50 with diabetes and smoking history have increased risk of nonarteritic ischemic optic neuropathy (NAION) with PDE5 inhibitors 9
• Sexual stimulation is necessary for effectiveness - incorrect use accounts for many treatment failures 3
• Stroke patients may have residual motor, sensory, and self-esteem difficulties that require communication and adjustment between partners 1

Bottom Line

Viagra is not absolutely contraindicated after stroke, but requires more careful cardiovascular assessment than in typical erectile dysfunction patients due to evidence of increased hemodynamic vulnerability in stroke survivors 2. The decision should prioritize cardiovascular safety over erectile function, with cardiology consultation for any patient whose risk is uncertain 3.