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 Yale-New Haven Hospital, New Haven, Connecticut, USA HealthLINK: Women's Health

April 12, 1999

News this month
Experts release latest
recommendations for
Viagra risk

Editor's note:
A study released in the June 1, 2000, New England Journal of Medicine adds to the evidence discussed in this 1999 HealthLINK that Viagra appears to be safe for men with heart disease. The more recent journal abstract can be accessed online.

In January, a joint committee of members of the American College of Cardiology and the American Heart Association issued a report on the "Use of Sildenafil (Viagra®) in Patients with Cardiovascular Disease." The drug has been prescribed to millions of men since its release in April, and some widely publicized deaths following its use have raised concerns among doctors and men diagnosed with heart disease. The report was written to appropriately caution physicians but not to unduly alarm them in their decisions to prescribe Viagra for patients with heart disease.

The mixing of Viagra and nitrate medications significantly increases the risk of potentially life-threatening low blood pressure.

After extensive review by other clinicians and by the federal Food & Drug Administration, the article was published in the Journal of the American College of Cardiology and in Circulation,an American Heart Association publication.

Viagra side effects
Viagra's side effects in otherwise healthy individuals are usually mild and include headache, flushing and slight decreases in blood pressure. In a very small number of cases, serious cardiovascular risks were noted, mainly in individuals taking nitrate medications. The mixing of Viagra and nitrate medications significantly increases the risk of potentially life-threatening low blood pressure. Viagra should not be prescribed to patients receiving any form of nitrate therapy under any circumstances.

Nitrate therapy and Viagra
don't mix
Nitrate therapy should not be given to anyone who has taken Viagra within the last 24 hours. Patients who develop angina pain after taking Viagra should caution caregivers not to administer nitroglycerin or any other form of nitrate therapy.

Risk categories
Other patients who are potentially at risk include those with active coronary ischemia - the medical term for a deficiency of blood to the heart either because of a spasm or an obstruction in the coronary arteries. This condition is often accompanied by angina, a sudden attack of chest pain, but occasionally ischemia produces no obvious symptoms and is called silent ischemia or silent angina.

Caution should be used in prescribing Viagra to patients with congestive heart failure, borderline low blood volume and low blood pressure or any patient who is being treated with a combination of drugs designed to lower blood pressure.

A summary of the report's recommendations follows:

  • Viagra should not be prescribed to anyone undergoing nitrate drug therapy.
  • Patients with stable coronary disease who are not on nitrate therapy should discuss the risks and benefits of the drug with their physicians.
  • Patients who suffer angina symptoms within 24 hours of taking Viagra must caution medical personnel not to give them nitroglycerin tablets.
  • Sedentary patients who plan to resume sexual activity with the help of Viagra may want to talk with their doctors about whether it's advisable to take a treadmill test to determine if they are at risk of stress-induced angina.
  • Patients who are taking a combination of drugs to lower their blood pressure, particularly those with congestive heart failure, should be cautioned about their potential risk.

Physician Referral Online

A free and confidential service
of Yale-New Haven Hospital.

Physician Referral Online
Using your own criteria, you can request information from a database of 900 area physicians who have registered to participate.

Request an appointment
We would be happy to assist you in scheduling an appointment with a member of the hospital's medical staff. Use the link above or call:

203-688-2000
or toll free
1-888-700-6543
to talk with a referral coordinator.
Michael S. Blum, MD

Viagra: is it safe for men with heart disease?

Many of my patients with heart disease have asked me if their condition makes it dangerous for them to take Viagra® (sidenafil citrate) for erectile dysfunction (ED). In fact, in spite of some widely publicized cases of deaths after Viagra use, many men with heart disease are good candidates for Viagra.

ED is common among male heart patients
Erectile dysfunction is relatively common among men with cardiovascular disease; roughly one out of four of these patients suffers bouts of impotence. As a cardiologist, I am pleased a drug such as Viagra has been developed to help solve what is clearly a very distressing condition for men and their partners. Viagra works very well for men whose ED is organic as opposed to psychological and, in most cases, it can be used safely.

“…many men with heart disease are good candidates for Viagra.”

Viagra and nitrate medications: a dangerous combination
Most of the reported deaths after taking Viagra stem from its use in combination with nitrate medications or the physical strain of sexual performance in men who are in poor health. Nitrate medications such as nitroglycerin have been mainstays of preventing and treating angina attacks (chest pain caused by poor blood flow to the heart muscle) for decades. The side effects of either Viagra or nitrate medications alone are mild. They both can cause slight drops in blood pressure, flushing, dizziness or headaches, but when used in combination, these effects are dramatically accentuated and may result in very dangerous and even fatal drops in blood pressure. Anyone taking nitrate medications for any reason must not take Viagra.

“It's critically important that anyone who has taken Viagra within 24 hours and experiences a medical emergency immediately notify medical personnel they have taken Viagra and should not be given nitrates.”

Your physical condition is a factor
Many people with heart disease lead sedentary lives, and sexual activity may precipitate attacks of angina. Sex places substantial demands on our cardiovascular systems. Our pulse races and blood pressures rise. Men who have not been sexually active for a long time and take Viagra may develop angina and seek emergency medical treatment.

It's critically important that anyone who has taken Viagra within 24 hours and experiences a medical emergency immediately notify medical personnel they have taken Viagra and should not be given nitrates. People with advanced liver or kidney disease should extend that 24-hour window to at least 48 hours since they may take longer to eliminate Viagra from their systems.

Prescribing Viagra
When I prescribe Viagra to my patients, I spend a good deal of time making sure they understand the danger of mixing Viagra with nitrate medication no matter what its form: pills, patches or sprays. It's always extremely important to notify anyone prescribing medication for you what drugs you already take.

Men with serious heart failure are usually on several medications and are probably not good candidates for Viagra. Patients scheduled for coronary angioplasty or open heart surgery should wait until after they recover from the procedure before they consider Viagra use.

Talk with your doctor
Many men with heart disease may assume they should not take Viagra, or they may be hesitant to discuss erectile problems with their physicians. An estimated 30 million men have ED, and drugs such as Viagra offer a safe, nonsurgical option for many of them. Those considering the drug should consult their doctors to determine if it is safe for them, and everyone should heed the warnings about combining Viagra with nitrates.

Dr. Blum is a cardiologist on staff at Yale-New Haven Hospital and an assistant professor in the Section of Cardiovascular Medicine at Yale University School of Medicine.

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