sildenafil-citrate and Coronary-Disease

Topics: Antihypertensive Agents; Contraindications; Coronary Disease; Drug Interactions; Drug Therapy, Combination; Erectile Dysfunction; Female; Humans; Hypertension, Pulmonary; Hypotension; Imidazoles; Male; Phosphodiesterase 5 Inhibitors; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones; Triazines; Vardenafil Dihydrochloride; Vasodilator Agents

Three different phosphodiesterase 5 (PDE5) inhibitors are currently available for the treatment of erectile dysfunction: sildenafil, vardenafil and tadalafil. The differences between these 3 are limited: tadalafil has a long duration of action, while vardenafil has a rapid onset of action after intake. Various studies have suggested that there is an improvement in the partners' sex lives when men use a PDE5 inhibitor for erectile dysfunction. The introduction of PDE5 inhibitors has renewed the interest in PDE inhibitors in general, for example in the treatment of pulmonary hypertension. In the near future PDE inhibitors may be used for various disorders as chronic obstructive pulmonary disease, benign prostatic hyperplasia, hypertension and coronary heart disease.

Topics: Carbolines; Coronary Disease; Erectile Dysfunction; Humans; Hypertension; Imidazoles; Male; Phosphodiesterase Inhibitors; Piperazines; Prostatic Hyperplasia; Pulmonary Disease, Chronic Obstructive; Purines; Sildenafil Citrate; Sulfones; Tadalafil; Treatment Outcome; Triazines; Vardenafil Dihydrochloride

Recent studies have highlighted the relation between erectile dysfunction (ED) and cardiovascular disease. In particular, the role of endothelial dysfunction and nitric oxide in ED and atherosclerotic disease has been elucidated. Given the large number of men receiving medical treatment for ED, concerns regarding the risk for sexual activity triggering acute cardiovascular events and potential risks of adverse or unanticipated drug interactions need to be addressed. A risk stratification algorithm was developed by the First Princeton Consensus Panel to evaluate the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. Patients were assigned to 3 categories: low, intermediate (including those requiring further evaluation), and high risk. This consensus study from the Second Princeton Consensus Conference corroborates and clarifies the algorithm and emphasizes the importance of risk factor evaluation and management for all patients with ED. The panel reviewed recent safety and drug interaction data for 3 phosphodiesterase (PDE)-5 inhibitors (sildenafil, tadalafil, vardenafil), with emphasis on the safety of these agents in men with ED and concomitant cardiovascular disease. Increasing evidence supports the role of lifestyle intervention in ED, specifically weight loss and increased physical activity, particularly in patients with ED and concomitant cardiovascular disease. Special management recommendations for patients taking PDE-5 inhibitors who present at the emergency department and other emergency medical situations are described. Finally, further research on the role of PDE-5 inhibition in treating patients with other medical or cardiovascular disorders is recommended.

Topics: Age Distribution; Aged; Angina Pectoris; Cardiovascular Agents; Cardiovascular Diseases; Comorbidity; Coronary Disease; Drug Interactions; Erectile Dysfunction; Humans; Incidence; Male; Middle Aged; Piperazines; Prognosis; Purines; Risk Assessment; Severity of Illness Index; Sildenafil Citrate; Sulfones; Survival Rate

Topics: 3',5'-Cyclic-GMP Phosphodiesterases; Adrenergic alpha-Antagonists; Arteriosclerosis; Blood Pressure; Carbolines; Contraindications; Coronary Disease; Cyclic GMP; Cyclic Nucleotide Phosphodiesterases, Type 5; Drug Interactions; Endothelium, Vascular; Erectile Dysfunction; Heart Rate; Humans; Hypotension; Imidazoles; Isosorbide Dinitrate; Male; Molecular Structure; Myocardial Infarction; Nitric Oxide Donors; Nitroglycerin; Phosphodiesterase Inhibitors; Phosphoric Diester Hydrolases; Piperazines; Purines; Randomized Controlled Trials as Topic; Sildenafil Citrate; Sulfones; Tadalafil; Triazines; Vardenafil Dihydrochloride; Vasodilation; Vasodilator Agents

Erectile dysfunction (ED) is defined as the inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance. ED may also be an early sign of cardiovascular disease. The main risk factors for coronary heart disease (high LDL, smoking, hypertension, diabetes) and ED are the same. ED after the diagnosis of coronary artery disease or myocardial infarction is also common.. Cardiac and metabolic expenditures during sexual intercourse will vary depending on the type of sexual activity. When oxygen uptake was measured in men, an average metabolic expenditure during stimulation and orgasm of 2.5 metabolic equivalents (METs) was found for woman-on-top coitus, and of 3.3 METs for man-on-top coitus (range 2.0-5.4 METs). However, coital death is rare, encompassing only 0.6% of all sudden death cases. A retrospective case-crossover study has shown that although sexual activity can trigger the onset of myocardial infarction, the relative risk in the 2 h after sexual activity was low (2.5; 95% confidence interval [CI] 1.7-3.7). Sexual activity was a likely contributor to the onset of myocardial infarction only 0.9% of the time. Regular exercise appears to prevent triggering. It has to be cautioned that these reassuring data should not be extrapolated to patients taking sildenafil, if they perform at higher cardiac and metabolic expenditures during coitus. The hemodynamic changes associated with sexual activity may be far greater with an unfamiliar partner, in unfamiliar settings, and after excessive eating and drinking. The Princeton Consensus Table for estimation of cardiovascular risk during sexual intercourse gives a first orientation regarding the question which patients can perform sex safely and which subgroup needs further diagnosis and treatment. PHOSPHODIESTERASE-5 INHIBITORS FOR ED TREATMENT: The introduction of sildenafil has been a valuable contribution to the treatment of ED. Sildenafil acts as a selective inhibitor of cyclic guanosine monophosphate-(cGMP-)specific phosphodiesterase type 5 (PDE 5), resulting in smooth muscle relaxation, vasodilation, and enhanced penile erection. Reported cardiovascular side effects in healthy males are headache, flushing, and < 10% decreases in systolic and diastolic blood pressures. Significant hypotension can be found in patients who are concurrently taking nitrates. On the basis of the pharmacokinetic profile of sildenafil, the co-administration of a nitrate within the first 24 h is likely to produce a severe, potentially lifethreatening hypotensive response and is therefore contraindicated. The risk of precipitating a cardiotoxic, hypotensive, or hemorrhagic event secondary to combining sildenafil (a PDE 5 inhibitor) with specific PDE 3 inhibitors such as milrinone and enoximone or with nonspecific PDE inhibitors such as theophylline and pentoxifylline is unlikely. Sildenafil is pred. Sildenafil is safe in healthy subjects. In a postmarketing study on 6,527 males, no increase of cardiovascular events was found. However, in older males with coronary heart disease, the risk of sildenafil and the risk of physical exercise during sexual intercourse contribute both to fatal outcomes. Of 69 cases reported to the FDA, 46 patients might have had a cardiovascular event, and in twelve a possible interaction with nitrate use has been reported. Sildenafil is absolutely contraindicated in patients taking long-acting nitrates, those with severe aortic stenosis, and patients with hypertrophic obstructive cardiomyopathy (HOCM). No nitrates should be used within 24 h of sildenafil use. Caution is necessary in patients with a combination of antihypertensive medications, and in patients with cardiac insufficiency. A "pre-Viagra" treadmill test to assess for the presence of stress-induced ischemia can be helpful for both the patient and the physician. If the patient can achieve > or = 5 METs without demonstrating ischemia, the risk of ischemia during coitus is low.. If severe hypotension occurs, aggressive fluid resuscitation is the first step, followed by administration of vasoactive drugs and, if necessary, by intraaortic balloon counterpulsation. If unstable angina or myocardial infarctions occurs after the use of sildenafil, the patient is treated according to the guidelines, but without nitrates.. Sexual activity is a cornerstone of quality of life. However, giving the incidence of "occult" cardiovascular disease in patients with ED and the indications and contraindications of PDE 5 inhibitors in patients with cardiovascular diseases, all patients with ED must be evaluated by a cardiovascular specialist.

Topics: Coronary Disease; Drug Interactions; Erectile Dysfunction; Hemodynamics; Humans; Hypotension; Male; Myocardial Infarction; Piperazines; Purines; Risk Factors; Sexual Behavior; Sildenafil Citrate; Sulfones; Vasodilator Agents

Selective inhibitors of phosphodiesterase type 5 prevent the breakdown of cyclic guanosine monophosphate resulting in enhanced penile erection and are used for the treatment of erectile dysfunction. Those agents, by way of vasodilator effects could interact with the systemic vasculature and could potentially affect the cardiac patient. During sexual intercourse, heart rate and blood pressure increase as with other forms of exertion. Stress to the heart during sexual intercourse is similar than that observed during other common daily activities. This article reviews the literature and provides recommendations regarding the evaluation of patients with known or suspected cardiac disease in whom therapy for erectile dysfunction is being considered. Patients who seek therapy for erectile dysfunction should undergo to individualized medical evaluation before a prescription is issued. Patients requiring therapy with long-acting nitrates should not receive prescriptions for phosphodiesterase inhibitors. Patients who are likely to develop angina with sexual exertion should not take phosphodiesterase inhibitors, as they may be tempted to take sublingual nitroglycerin. Stress testing is indicated if exercise capacity is uncertain or if significant myocardial ischemia is suspected.

Topics: Clinical Trials as Topic; Contraindications; Coronary Disease; Drug Interactions; Erectile Dysfunction; Exercise Test; Hemodynamics; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Purines; Risk Assessment; Sildenafil Citrate; Sulfones; Vasodilator Agents

Risk factors for erectile dysfunction (ED) (hypertension, diabetes, smoking, lipid abnormality) are also risk factors for coronary artery disease. However, most cardiologists do not routinely ask about ED and patients often are reluctant or embarrassed to discuss it. We determined how common ED was in a group of patients with chronic stable coronary artery disease.. We administered the validated Sexual Health Inventory for Men (SHIM) 5-item questionnaire, based on the International Index of Erectile Function questionnaire, to 76 men with chronic stable coronary artery disease during routine outpatient cardiology visits. Most of these men had not previously discussed ED with their cardiologist.. The mean patient age was 64 years (range 40 to 82). The questionnaire took about 5 minutes to complete. Of the patients 47% were on beta blockers, 92% statins, 28% diuretics. SHIM score was 21 or less in 53 men (70%), which is indicative of ED. Of the patients 75% had some difficulty achieving erections (question 2) and 67% had some difficulty maintaining an erection after penetration (question 3). The questionnaire reflected successful sildenafil treatment in 4 patients (SHIM scores 23 to 25). If these 4 men are included as having had ED then 57 of 76 (75%) had ED or recent history of ED.. ED is extremely common in men with chronic coronary artery disease (affecting approximately 75%) yet most cardiologists do not ask about it. The SHIM is a useful, quick and inexpensive tool for discussion and diagnosis of ED in this population. Although it is well established that cardiovascular risk factors are associated with erectile dysfunction, once it is present there is mixed information on whether treating the risk factors will treat the ED. Problems appear to be that lifestyle modification in midlife may simply be too late to effect a change, and some antihypertensive and lipid lowering drugs may actually exacerbate ED. Oral therapy for ED, namely the PDE5 inhibitors, is effective and safe in most cardiac and hypertensive patients. Organic nitrates such as nitroglycerin remain a contraindication to the concomitant use of these drugs. Guidelines for treatment of ED in the cardiac patient issued by the American College of Cardiology/American Heart Association and Princeton Guidelines may be useful in the approach to the cardiac patient with ED.

Topics: Comorbidity; Coronary Disease; Diabetic Angiopathies; Erectile Dysfunction; Heart Diseases; Humans; Hypertension; Imidazoles; Life Style; Male; Penile Erection; Piperazines; Purines; Risk Factors; Sildenafil Citrate; Smoking; Sulfones; Triazines; Vardenafil Dihydrochloride

THE CONTEXT: Patients with coronary heart disease are generally males aged more than 55 and in whom the question of sexual activity must be evoked, not only with regard to the risks involved with the sexual act itself but also regarding the management of an eventual erectile dysfunction. POSITIVE DATA: A negative and maximal for the age stress test is of predictive value and can eliminate the hypothesis of recurrent coronary ischaemia during sexual intercourse. Drug-induced effects on the libido and erectile function are known but only led to suspension of treatment in one out 438 patients treated for one year.. In the case of documented erectile dysfunction, the combination of sildenafil nitrate derivatives or NO suppliers is formally contra-indicated because of the risk of hypotension. Post-marketing registers and specific studies in patients with coronary heart disease demonstrate the good haemodynamic and coronary tolerance to sildenafil in this category of patient, so long as the contra-indications are respected. The Princeton Consensus Panel has proposed a therapeutic strategy adapted to each patient and according to their level of risk and its treatment.

Topics: Coronary Disease; Erectile Dysfunction; Humans; Male; Middle Aged; Phosphodiesterase Inhibitors; Piperazines; Purines; Risk Assessment; Risk Factors; Sildenafil Citrate; Sulfones

Since the etiology of erectile dysfunction is frequently related to endothelial dysfunction, a problem in common with much vascular disease, erectile dysfunction disproportionately affects patients with cardiovascular disease. With the development of phosphodiesterase 5 inhibitors, the first of which was sildenafil (Viagra), an effective oral medication became available. The question of safety of these drugs, especially in patients with latent or overt coronary artery disease, is of concern. Sildenafil relaxes smooth muscle and therefore lowers systolic and diastolic blood pressure slightly. With organic nitrates, the drop in blood pressure is potentiated, at times dangerously, thereby making it contraindicated to take nitrates within 24 hours of using sildenafil. In double-blind, placebo-controlled trials, there was no difference between sildenafil subjects and control patients in the incidence of myocardial infarction, cardiovascular, and total deaths. Coronary disease patients with stable angina, controlled on medications, were included in the trials. Therefore, sildenafil, as a drug, is safe in such patients. With a patient with coronary artery disease suddenly engaging in the physical exercise associated with sexual intercourse, there is the danger of increased risk of precipitating myocardial infarction or death. The cardiovascular metabolic cost of sexual activity is reviewed and appears to be approximately at the level of 3-5 metabolic equivalents of exercise. Sexual activity occurs within 2 hours of the onset of an acute myocardial infarction in <1.0% of patients. Although sexual intercourse is estimated to increase the risk of myocardial infarction by a factor of 2x, there is still only a very small increase in risk, a risk acceptable to patients who feel their quality of life will be markedly improved by their ability to engage in sexual activity.

Topics: Coronary Disease; Erectile Dysfunction; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Topics: Algorithms; Cardiovascular System; Coronary Disease; Erectile Dysfunction; Heart Diseases; Humans; Hypertension; Male; Piperazines; Purines; Referral and Consultation; Risk Assessment; Sildenafil Citrate; Sulfones; Vasodilator Agents

Despite isolated reports of myocardial infarction and sudden cardiac death in men taking sildenafil for erectile dysfunction, clinical evidence shows the drug to be safe, effective, and well tolerated in most men with coronary artery disease. Nevertheless, caution is advised in specific instances.

Topics: Contraindications; Coronary Disease; Death, Sudden, Cardiac; Drug Interactions; Erectile Dysfunction; Hemodynamics; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

As a potent and selective inhibitor of cyclic guanosine monophosphate-specific phosphodiesterase 5 (PDE5), sildenafil citrate (Viagra) is safe and effective in men with erectile dysfunction (ED) of diverse aetiologies, including patients with common cardiovascular diseases who are not receiving organic nitrates or nitrate donor drugs. In retrospective analyses of extensive clinical trials, sildenafil treatment for ED was not associated with any increase in cardiac risk. In haemodynamic studies, sildenafil produced small decreases in systemic and pulmonary blood pressure but caused no adverse cardiovascular effects in specific populations of men with coronary heart disease. Sildenafil also caused no significant changes in coronary blood flow but had a positive effect on coronary flow reserve in men with severe coronary artery disease. Together with findings from other studies, these data suggest that PDE5 may play an important role in the regulation of coronary blood flow in the healthy and diseased heart.

Topics: Animals; Blood Platelets; Clinical Trials as Topic; Coronary Circulation; Coronary Disease; Coronary Vessels; Dogs; Humans; Impotence, Vasculogenic; Male; Myocardial Contraction; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Oral drugs are a well-established, first-line therapy for erectile dysfunction. As a result of the success of sildenafil, a plethora of new drugs for erectile dysfunction are on the horizon. Apomorphine and IC351 are in late phase III development. Vardenafil (Bayer, New Haven, CT), a PDE5 inhibitor, and the combination of yohimbine and L-arginine (NitroMed, Boston, MA) are in early phase III development. Early clinical and preclinical studies are investigating new phosphodiesterase inhibitors, cyclic AMP activators, alpha-adrenergic antagonists, dopamine agonists, melanocyte-stimulating hormone, potassium channel modulators, endothelin antagonists, and new nitric oxide donors. The future is bright for this infant field of sexual pharmacotherapy.

Topics: 3',5'-Cyclic-GMP Phosphodiesterases; Administration, Oral; Apomorphine; Cardiovascular System; Contraindications; Coronary Disease; Cyclic Nucleotide Phosphodiesterases, Type 5; Dopamine Agonists; Erectile Dysfunction; Heart; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Prostatectomy; Purines; Sildenafil Citrate; Spinal Cord Injuries; Sulfones

Topics: Adult; Aged; Contraindications; Coronary Disease; Drug Interactions; Erectile Dysfunction; Humans; Hypertension; Male; Middle Aged; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Erection is initiated through the parasympathetic nervous system, activation of which overrides the sympathetic tone that maintains the penis in a nonerectile (flaccid) state. This state is maintained mainly through the release of norepinephrine from penile adrenergic nerves. Norepinephrine contracts the vasculature and cavernosal smooth muscle. Arousal/erection is associated with a decrease of norepinephrine release in the penis, with a release of nitric oxide, and with a reduction in penile smooth muscle tone. It is also associated with minor cardiovascular changes. Heart rate increases by 4-8 beats per minute, on average, and the rate-pressure product and oxygen consumption increase by approximately 25%. There may be no changes in systemic venous norepinephrine concentrations; systemic venous epinephrine concentrations increase by about 60%. Drugs initiating or enhancing erection act by inhibiting norepinephrine-induced contraction (e.g., phentolamine) or by enhancing or directly inducing relaxation of the corpora cavernosa and the penile vasculature (e.g., sildenafil). Despite potentially negative hemodynamic actions when given parenterally, oral phentolamine-in doses required for enhancing erection-appears to produce few cardiovascular adverse effects. The hemodynamic effects of sildenafil are small, even in patients with coronary artery disease. However, the effects of the drug on human myocardium have not been conclusively established, and should be further investigated. As judged by available information, the cardiac risk associated with erection, with or without enhancement of drugs currently used for treatment of erectile dysfunction, is low.

Topics: Adrenergic alpha-Antagonists; Animals; Coronary Disease; Erectile Dysfunction; Heart; Humans; Male; Norepinephrine; Penile Erection; Phentolamine; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Diagnosis of erectile dysfunction is important because sildenafil may not be the proper therapy for patients with underlying major diseases such as coronary sclerosis, arteriosclerosis of the stroke vessels, depression, etc., where erectile dysfunction is just a symptom of the disease.

Topics: Contraindications; Coronary Disease; Erectile Dysfunction; Humans; Male; Piperazines; Purines; Sildenafil Citrate; Sulfones

Although contraindicated, there are situations when a patient who has recently taken a phosphodiesterase 5 inhibitor (e.g., sildenafil) might need intravenous nitroglycerin (NTG) treatment. This study determined if, and at what dose, intravenous NTG could be administered safely to men with coronary artery disease who had recently ingested sildenafil.. Double-blind, placebo-controlled, randomized, crossover trial.. Four clinical practice sites in Canada, Scotland, and the United States.. A total of 34 men (>or=35 yrs) with a history of angina pectoris and coronary artery disease (>50% stenosis of at least one coronary artery), most of whom were taking antihypertensives.. Sildenafil (100 mg) or placebo (single dose; crossover after 3-7 days) followed 45 mins later by escalating doses of intravenous NTG (160 microg/min maximum).. After sildenafil, there were slightly greater maximum (supine) blood pressure decreases and heart rate increases (e.g., 4 to 6 mm Hg [systolic] and

Topics: Aged; Aged, 80 and over; Blood Circulation; Coronary Disease; Cross-Over Studies; Dose-Response Relationship, Drug; Double-Blind Method; Drug Interactions; Drug-Related Side Effects and Adverse Reactions; Humans; Infusions, Intravenous; Male; Middle Aged; Nitroglycerin; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones; Vasodilator Agents

To investigate whether sildenafil citrate, a selective phosphodiesterase type 5 inhibitor, may improve endothelial vasomotor and fibrinolytic function in patients with coronary heart disease.. Randomised double blind placebo controlled crossover study.. 16 male patients with coronary heart disease and eight matched healthy men received intravenous sildenafil or placebo. Bilateral forearm blood flow and fibrinolytic parameters were measured by venous occlusion plethysmography and blood sampling in response to intrabrachial infusions of acetylcholine, substance P, sodium nitroprusside, and verapamil.. Forearm blood flow and acute release of tissue plasminogen activator.. Mean arterial blood pressure fell during sildenafil infusion from a mean (SEM) of 92 (1) to 82 (1) mm Hg in patients and from 94 (1) to 82 (1) mm Hg in controls (p < 0.001 for both). Sildenafil increased endothelium independent vasodilatation with sodium nitroprusside (p < 0.05) but did not alter the blood flow response to acetylcholine or verapamil in patients or controls. Substance P caused a dose dependent increase in plasma tissue plasminogen activator antigen concentrations (p < 0.01) that was unaffected by sildenafil in either group.. Sildenafil does not improve peripheral endothelium dependent vasomotor or fibrinolytic function in patients with coronary heart disease. Phosphodiesterase type 5 inhibitors are unlikely to reverse the generalised vascular dysfunction seen in patients with coronary heart disease.

Topics: 3',5'-Cyclic-GMP Phosphodiesterases; Coronary Disease; Cross-Over Studies; Cyclic Nucleotide Phosphodiesterases, Type 5; Double-Blind Method; Endothelium, Vascular; Fibrinolysis; Forearm; Humans; Male; Middle Aged; Phosphodiesterase Inhibitors; Phosphoric Diester Hydrolases; Piperazines; Purines; Sildenafil Citrate; Sulfones; Tissue Plasminogen Activator

This was a double-blind, placebo-controlled, flexible-dose study of the efficacy and safety of sildenafil in men with erectile dysfunction (ED) and clinically stable coronary artery disease (CAD). Patients were randomized to receive sildenafil or placebo for 12 weeks. Primary outcomes were questions 3 and 4 of the International Index of Erectile Function (IIEF). Secondary outcomes included the other IIEF questions and functional domains, the Life Satisfaction Checklist, the Erectile Dysfunction Inventory of Treatment Satisfaction, 2 global efficacy assessment questions, and intercourse success rate. By week 12, sildenafil-treated patients (n = 70) showed significant improvements on questions 3 and 4 compared with placebo-treated patients (n = 72; p <0.01). Larger percentages of sildenafil-treated patients reported improved erections (64%) and improved intercourse (65%) compared with placebo-treated patients (21% and 19%, respectively). Sildenafil-treated patients were highly satisfied with treatment and their sexual life compared with placebo-treated patients. Forty-seven percent of sildenafil- and 32% of placebo-treated patients experienced adverse events, including transient headache, hypertension, flushing, and dyspepsia. There were no serious drug-related cardiovascular effects. Thus, sildenafil is an effective and well-tolerated treatment for ED in men with CAD. Sildenafil was not associated with additional safety risks in this patient population.

Topics: 3',5'-Cyclic-GMP Phosphodiesterases; Coronary Disease; Double-Blind Method; Erectile Dysfunction; Humans; Male; Middle Aged; Outcome Assessment, Health Care; Patient Satisfaction; Penile Erection; Piperazines; Prospective Studies; Purines; Safety; Sildenafil Citrate; Sulfones; Time Factors; Vasodilator Agents

The cardiovascular effects of sildenafil are important because of the frequent presence of underlying cardiac disease in men with erectile dysfunction and reports indicating serious cardiac events temporally associated with the use of this drug.. We assessed the systemic, pulmonary, and coronary hemodynamic effects of oral sildenafil (100 mg) in 14 men (mean [+/-SD] age, 61+/-11 years) with severe stenosis of at least one coronary artery (stenosis of >70 percent of the vessel diameter) who were scheduled to undergo percutaneous coronary revascularization. Blood-flow velocity and flow reserve were assessed with a Doppler guidewire in 25 coronary arteries, including 13 severely diseased arteries (mean stenosis, 78+/-7 percent) and 12 arteries without stenosis, used as a reference; maximal hyperemia was induced (to assess flow reserve) with the intracoronary administration of adenosine both before and after sildenafil.. Oral sildenafil produced only small decreases (<10 percent) in systemic arterial and pulmonary arterial pressures, and it had no effect on pulmonary-capillary wedge pressure, right atrial pressure, heart rate, or cardiac output. There were no significant changes in average peak coronary flow velocity, coronary-artery diameter, volumetric coronary blood flow, or coronary vascular resistance. Coronary flow reserve at base line was lower in the stenosed arteries (1.26+/-0.26) than in the reference arteries (2.19+/-0.44) and increased about 13 percent in both groups of arteries combined after the administration of sildenafil (from 1.70+/-0.59 to 1.92+/-0.72, P=0.003). The ratio of coronary flow reserve in coronary arteries with stenosis to that in the reference arteries (0.57+/-0.14) was not affected by sildenafil.. No adverse cardiovascular effects of oral sildenafil were detected in men with severe coronary artery disease.

Topics: Coronary Disease; Coronary Vessels; Hemodynamics; Humans; Male; Middle Aged; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Topics: Coronary Disease; Drug Interactions; Drug-Related Side Effects and Adverse Reactions; Humans; Male; Nitroglycerin; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones; Vasodilator Agents

To assess sexual dysfunction in sexually active men after radical cystectomy (RC) and to determine whether sildenafil citrate can improve erectile dysfunction after surgery.. The baseline and follow-up data from 49 sexually active male patients (mean age 57.8 +/- 9.1 years) undergoing RC (1995 to 2002) were obtained. Of the 49 patients, 16 (33%) had undergone nerve-sparing RC; 38 (78%) had undergone orthotopic diversion; 8 (16%) had undergone ileal conduit diversion; and 3 (6%) had undergone cutaneous continent diversion. The data were assessed using the abridged 5-item International Index of Erectile Function questionnaire, referred to as the Sexual Health Inventory for Men (SHIM).. At a mean follow-up of 47.6 +/- 22.7 months, the total mean SHIM score decreased from 22.08 +/- 3.96 to 4.33 +/- 5.72 after RC (P <0.05). Of the 49 patients, 42 (86%) did not have erections sufficient for vaginal penetration. Of these 42 patients, 22 (52%) tried sildenafil citrate. Of these 22 patients, only 2 (9%) responded positively, with a total mean SHIM score of 23.50 +/- 2.12. Although the mean SHIM score after orthotopic substitution (5.24 +/- 6.21) was statistically significant compared with that after ileal conduit (1.13 +/- 0.33) and cutaneous continent (1.33 +/- 0.58) diversions, this was not clinically significant.. Male erectile dysfunction after RC is a prevalent problem. In our series, only 9 (14%) of 49 sexually active men were potent after surgery. Of these 9 potent patients, 8 (89%) had undergone nerve-sparing RC. Of concern, only 52% of the patients with erectile dysfunction sought treatment after RC.

Topics: Aged; Carcinoma; Comorbidity; Coronary Disease; Cystectomy; Diabetes Mellitus; Drug Evaluation; Drug Resistance; Erectile Dysfunction; Follow-Up Studies; Humans; Hypertension; Male; Middle Aged; Patient Acceptance of Health Care; Patient Satisfaction; Peripheral Nerve Injuries; Piperazines; Purines; Quality of Life; Sildenafil Citrate; Spouses; Sulfones; Surveys and Questionnaires; Urinary Bladder Neoplasms; Urinary Diversion

The vast majority of men who experience some form of erectile dysfunction (ED) do not seek medical advice, mainly due to embarrassment and social stigma. They often prefer to seek unorthodox and covert methods of treatment. Unprescribed medication for ED is dangerous because of the strong association between ED and coronary heart disease. Published guidelines already exist for the management of patients presenting with sexual dysfunction and cardiovascular risks. In this case report we highlight that ED itself is a risk factor for occult CHD and illustrate the need for careful medical assessment and adherence to published guidelines for the management of ED.

Topics: Adult; Coronary Disease; Erectile Dysfunction; Humans; Internet; Male; Nonprescription Drugs; Piperazines; Purines; Risk Factors; Risk-Taking; Sildenafil Citrate; Sulfones; Vasodilator Agents

Topics: Blood Pressure; Coronary Disease; Erectile Dysfunction; Humans; Male; Myocardial Infarction; Piperazines; Purines; Sildenafil Citrate; Sulfones; Vasodilator Agents

Topics: Adult; Aged; Clinical Trials as Topic; Contraindications; Coronary Disease; Drug Interactions; Erectile Dysfunction; Hemodynamics; Humans; Male; Middle Aged; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Topics: Aged; Coronary Disease; Electrocardiography; Erectile Dysfunction; Exercise Test; Heart Failure; Hemodynamics; Humans; Male; Middle Aged; Phosphodiesterase Inhibitors; Piperazines; Product Surveillance, Postmarketing; Purines; Risk; Sildenafil Citrate; Sulfones; Vasodilator Agents

Sildenafil is a medication increasingly prescribed to improve sexual function in patients who have erectile dysfunction. Because a major contraindication to the use of sildenafil is a history of coronary disease and the concomitant use of nitrates, it becomes increasingly important for cardiologists to prescribe this medication. We evaluated the nature of discussions in all 70 patients for whom sildenafil was prescribed in a cardiology practice between April and July 1998. We used a standardized questionnaire to determine the patients' perspective on the sexual history and the extent to which they wanted their physicians to take a detailed history about sexuality. A separate chart review evaluated the nature of physicians' discussions about sexual functioning before sildenafil was prescribed. Fifty-five of the 70 patients (79%) responded to the survey. The majority of patients (98%) felt that physicians should talk with patients about sexual functioning. However, only 73% of patients believed their doctor was comfortable talking with them about this subject. Sixty percent of patients reported that their doctor had ever talked with them about erectile function and only 15% had ever had a discussion with their doctors about specific difficulties during intercourse. Based on the results of the chart review, only 24% of the patients ever specifically discussed the used of sildenafil with their physician prior to the time that it was prescribed. The results of the study suggest that patients with coronary disease erectile dysfunction are comfortable talking with their physicians about sexual functioning, but these conversations occur infrequently.

Topics: Aged; Aged, 80 and over; Cardiovascular Diseases; Contraindications; Coronary Disease; Erectile Dysfunction; Humans; Male; Middle Aged; Patient Compliance; Phosphodiesterase Inhibitors; Piperazines; Practice Patterns, Physicians'; Purines; Quality of Life; Sexuality; Sildenafil Citrate; Sulfones; Surveys and Questionnaires

Topics: Contraindications; Coronary Disease; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones; Vasodilator Agents

Our aim was to determine whether sildenafil citrate (Viagra) unfavorably alters coronary perfusion in canine models of coronary artery stenosis.. Concern has been raised that sildenafil may exacerbate ischemia in patients with coronary artery disease. However, the effects of sildenafil on coronary perfusion are largely unexplored.. Using anesthetized dogs, a micromanometer constrictor was applied to either an intact coronary artery (model of stable hypoperfusion: Protocol 1) or a site of arterial injury (model of recurrent platelet-mediated thrombosis: Protocol 2). After monitoring coronary flow for 1 h, dogs received two escalating, clinically relevant doses of sildenafil or placebo. Perfusion was assessed during the initial hour pretreatment, for 1 h following dose 1 and 1 h following dose 2 by measuring the area of the flow-time profile, normalized to baseline flow x 60 min. Interaction between sildenafil and adenosine-mediated inhibition of platelet aggregation was evaluated by in vitro platelet aggregometry (Protocol 3).. In Protocol 1, flow-time area was maintained at 50% to 60% of baseline in both placebo- and sildenafil-treated groups. In Protocol 2, controls exhibited an expected modest, temporal adenosine-mediated improvement in flow-time area (from 40 +/- 5% to 61 +/- 7%; p < .05) while in contrast, perfusion in sildenafil-treated dogs remained unchanged (37 +/- 6% vs. 33% to 35% before vs. after treatment). In vitro aggregometry confirmed that sildenafil rendered platelets refractory to the inhibitory effects of adenosine receptor stimulation.. Sildenafil did not exacerbate ischemia in canine models of coronary stenosis. However, in the setting of recurrent thrombosis, sildenafil-treated dogs were apparently unresponsive to the platelet inhibitory effects of endogenous adenosine.

Topics: Adenosine; Animals; Blood Flow Velocity; Coronary Circulation; Coronary Disease; Disease Models, Animal; Dogs; Piperazines; Platelet Aggregation; Purines; Sildenafil Citrate; Sulfones

Topics: Coronary Disease; Electrocardiography; Erectile Dysfunction; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Purines; Risk Factors; Sildenafil Citrate; Sulfones

Topics: Apomorphine; Contraindications; Coronary Disease; Drug Interactions; Erectile Dysfunction; Humans; Male; Molsidomine; Nitrates; Piperazines; Purines; Sildenafil Citrate; Sulfones

Topics: Contraindications; Coronary Disease; Erectile Dysfunction; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Purines; Risk; Sildenafil Citrate; Sulfones

Topics: Adult; Coronary Disease; Electrocardiography; Emergency Treatment; Humans; Hypercholesterolemia; Male; Myocardial Infarction; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones; Syncope

Topics: Cause of Death; Coronary Disease; Hemodynamics; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Topics: Blood Flow Velocity; Coronary Disease; Coronary Vessels; Erectile Dysfunction; Hemodynamics; Humans; Male; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Sildenafil citrate (Viagra) is indicated for the treatment of erectile dysfunction. Large and sudden decreases in systemic blood pressure were reported in a substantial number of patients taking sildenafil citrate combined with nitroglycerin. We studied the effect of sildenafil citrate on the relationship between changes in systemic blood pressure and coronary blood flow.. Healthy male beagles were used to assess systemic blood pressure, pulmonary arterial pressure, and flow in the left circumflex artery (in which a critical stenosis was established) and left anterior descending coronary artery. After measurement of the hemodynamic variables, 2 mg/kg sildenafil citrate was administered via a nasogastric tube. Hemodynamic changes were monitored for 1 hour. Subsequently, the acute effect of nitrate combined with sildenafil citrate was studied by the bolus injection of 0.2 mg isosorbide dinitrate before and after sildenafil citrate. Systemic blood and pulmonary arterial pressures and circumflex flow did not change during this study; however, left anterior descending coronary arterial flow increased from 16.0+/-5.8 to 24.6+/-8.7 mL/min 1 hour after administration of sildenafil citrate. The prolongation of systemic blood pressure decrease and the circumflex flow decrement induced by isosorbide dinitrate after sildenafil citrate were significantly larger and longer than those before sildenafil citrate.. Sildenafil citrate had the effect of vasodilation in a normal coronary artery; however, a combined effect with nitrate resulted in large and protracted decreases in systemic blood pressure and coronary blood flow in vessels with critical stenosis.

Topics: Administration, Oral; Animals; Blood Flow Velocity; Blood Pressure; Cardiac Output; Coronary Artery Bypass; Coronary Circulation; Coronary Disease; Coronary Vessels; Dogs; Drug Synergism; Heart; Heart Rate; Injections; Isosorbide Dinitrate; Male; Phosphodiesterase Inhibitors; Piperazines; Pulmonary Artery; Purines; Sildenafil Citrate; Stroke Volume; Sulfones; Vasodilator Agents

Topics: 3',5'-Cyclic-GMP Phosphodiesterases; Coitus; Coronary Disease; Erectile Dysfunction; Humans; Male; Middle Aged; Phosphodiesterase Inhibitors; Piperazines; Purines; Risk Assessment; Sildenafil Citrate; Sulfones

Topics: 3',5'-Cyclic-GMP Phosphodiesterases; Controlled Clinical Trials as Topic; Coronary Disease; Erectile Dysfunction; Humans; Male; Nitric Oxide; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

Topics: 3',5'-Cyclic-GMP Phosphodiesterases; Coronary Disease; Drug Synergism; Erectile Dysfunction; Humans; Male; Nitrates; Phosphodiesterase Inhibitors; Piperazines; Purines; Sildenafil Citrate; Sulfones

There has been considerable media attention surrounding the commercialisation of Sildenafil. The advice of cardiologists is often solicited before its prescription because of its potential side effects; the cardiovascular stress due to sexual activity is generally modest, both in normal subjects and coronary patients with, however, important individual variations, the "legitimate" nature of the intercourse seeming to be one of the principal factors. Recent coronary events, poorly controlled hypertension and uncompensated cardiac failure are the main contra-indications; the prescription should be based on the results of maximal exercise stress testing in patients at risk.

Topics: Adolescent; Adult; Arrhythmias, Cardiac; Coronary Disease; Erectile Dysfunction; Female; Humans; Male; Middle Aged; Myocardial Ischemia; Phosphodiesterase Inhibitors; Piperazines; Purines; Risk Factors; Sexuality; Sildenafil Citrate; Stress, Physiological; Sulfones