Is sildenafil (Viagra) effective for primary prevention of cardiovascular disease (cv disease)?

Sildenafil Is Not Recommended for Primary Prevention of Cardiovascular Disease

Sildenafil has no established role in the primary prevention of cardiovascular disease and should not be used for this indication. The major cardiovascular prevention guidelines from the ACC/AHA make no mention of sildenafil or any phosphodiesterase-5 inhibitor as a preventive therapy for cardiovascular disease 1.

Evidence-Based Primary Prevention Strategies

The 2019 ACC/AHA Guideline on Primary Prevention of Cardiovascular Disease clearly outlines the cornerstone interventions for preventing ASCVD 1:

Lifestyle Interventions (First-Line)

• At least 150 minutes per week of moderate-intensity physical activity or 75 minutes per week of vigorous-intensity physical activity 1
• Heart-healthy dietary patterns including the DASH diet to reduce cardiovascular risk 1
• Complete tobacco cessation with assistance and strong advice to quit at every healthcare visit 1
• Weight management through dietary modifications and exercise 1

Pharmacologic Interventions (When Indicated)

• Statin therapy is first-line pharmacologic treatment for primary prevention in patients with:

  • LDL cholesterol ≥190 mg/dL 1
  • Diabetes mellitus, age 40-75 years 1
  • 10-year ASCVD risk ≥10% 1
  • Consider for 10-year ASCVD risk 7.5-10% 1

• Antihypertensive medications for blood pressure ≥130/80 mm Hg in patients with 10-year ASCVD risk ≥10% 1

• Metformin as first-line therapy for type 2 diabetes, with consideration of SGLT-2 inhibitors or GLP-1 receptor agonists for additional cardiovascular risk reduction 1

• Aspirin use infrequently in routine primary prevention due to lack of net benefit 1

Sildenafil's Actual Cardiovascular Profile

Sildenafil is FDA-approved only for erectile dysfunction and pulmonary arterial hypertension, not cardiovascular disease prevention 2:

Hemodynamic Effects

• Causes modest, transient reductions in blood pressure (approximately -8/-5.5 mm Hg systolic/diastolic) 3, 4, 5
• Does not affect cardiac contractility or increase heart rate 4
• Has mild vasodilating effects in coronary circulation but does not improve ischemia or exercise capacity 4

Safety in Cardiovascular Disease

• Generally safe in men with stable cardiovascular disease when used for erectile dysfunction 6, 7, 4
• Absolutely contraindicated with nitrates due to life-threatening hypotension risk 2, 3, 4
• No evidence of increased myocardial infarction or death rates when used appropriately for erectile dysfunction 6, 7, 4

Lack of Preventive Benefit

• In idiopathic pulmonary fibrosis trials, sildenafil showed no significant benefit on mortality (RR 0.51; 95% CI 0.1-2.72) 1
• No randomized controlled trials have evaluated sildenafil for primary prevention of cardiovascular disease 1

Critical Clinical Pitfall

Do not confuse sildenafil's cardiovascular safety profile (when used for erectile dysfunction) with any preventive cardiovascular benefit. The fact that sildenafil is generally safe in patients with stable cardiovascular disease does not mean it prevents cardiovascular events 6, 7, 4.

The Bottom Line

For primary prevention of cardiovascular disease, clinicians should focus on the evidence-based interventions outlined in the 2019 ACC/AHA guidelines: lifestyle optimization (diet, exercise, smoking cessation), statins for appropriate risk groups, blood pressure control, and diabetes management 1. Sildenafil has no role in this paradigm and should only be prescribed for its approved indications of erectile dysfunction or pulmonary arterial hypertension 2.