Correspondence
Acute Myocardial Infarction after the Use of Sildenafil
N Engl J Med 1999; 341:700August 26, 1999
- Article
To the Editor:
A 70-year-old man came to his physician with acute myocardial infarction after self-administration of sildenafil (Viagra) and nitrates, a case highlighting a new trigger for acute myocardial infarction. He had a history of hypertension and hypercholesterolemia, and atypical chest pain had developed a few weeks previously. A thallium exercise test revealed neither angina nor evidence of ischemia at a heart rate of 146 beats per minute, and exercise capacity was normal for his age. Two weeks after the exercise test, another episode of chest pain occurred, one and a half hours after he took sildenafil that had been provided by a friend. Fifteen minutes after the onset of chest pain, the patient took two sublingual nitroglycerin tablets given to him by his mother. His chest pain continued for eight hours despite the use of aspirin and acetaminophen. He then presented to his physician's office, where an electrocardiogram revealed new right bundle-branch block, Q waves in leads V1 through V4, and 1-to-2-mm elevation of the ST segment with upward sloping in leads V2 through V6, indicating recent anteroseptal myocardial infarction. Elevated serum troponin I and creatine kinase levels were found, confirming the diagnosis of acute myocardial infarction.
Emergency coronary angiography revealed 95 percent occlusion of the mid–left anterior descending artery and 60 percent occlusion of the posterior descending artery. An intracoronary stenting procedure of the left anterior descending artery was then performed without complications.
The use of sildenafil presents a risk of acute myocardial infarction in patients who have hypotension as a result of drug regimens (such as nitrates) or low blood volume. Sildenafil produces a transient reduction in blood pressure.1,2 On the basis of his coronary angiogram, it is likely that this patient had preexisting coronary artery disease, despite the absence of perfusion defects on his exercise test. Thus, the use of sildenafil, in combination with nitroglycerin, may have led to a critical lowering of blood pressure that exacerbated his ischemia and resulted in acute myocardial infarction.
The Food and Drug Administration has reported 128 nonviolent deaths in the United States among men who received prescriptions for sildenafil. Of these deaths, 34 percent occurred within four or five hours after sildenafil was used, and approximately 70 percent of the men who died had risk factors for cardiovascular or cerebrovascular disease.3
Sildenafil is widely available through the Internet without contact with a physician and through unregulated, illicit trade. Patients who are reluctant to reveal erectile dysfunction to their physicians can easily self-administer the drug. Therefore, men should be warned of the risks of taking sildenafil and nitrates concurrently if they have received a prescription for only one or the other. Also, on-line medical care must be fully investigated, and guidelines should be established regarding the prescription of drugs over the Internet.
3 ReferencesRohit R. Arora, M.D.
Michael Timoney
Columbia–Presbyterian Medical CenterLisa Melilli, M.P.H.
Columbia University School of Public Health, New York, NY 100321
Cheitlin MD ,Hutter AM Jr ,Brindis RG , et al. Use of sildenafil (Viagra) in patients with cardiovascular disease. Circulation 1999;99:168-177
Web of Science | Medline2
Goldstein I ,Lue TF ,Padma-Nathan H ,Rosen RC ,Steers WD ,Wicker PA . Oral sildenafil in the treatment of erectile dysfunction. N Engl J Med 1998;338:1397-1404[Erratum, N Engl J Med 1998;339:59.]
Full Text | Web of Science | Medline3
Viagra (sildenafil citrate) tablets (revised label). New York: Pfizer, November, 1998. (Or see: http://www.fda.gov/cder/consumerinfo/viagra/prescrib.pdf.)
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A. Rufa, A. Cerase, L. Monti, M.T. Dotti, A. Giorgio, F. Sicurelli, A. Federico. (2007) Recurrent venous thrombosis including cerebral venous sinus thrombosis in a patient taking sildenafil for erectile dysfunction. Journal of the Neurological Sciences 260:1-2, 293-295
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Lorna Hazell, Andrew Boshier, Scott Harris, Lynda V. Wilton, Saad A.W. Shakir. (2007) An observational cohort study investigating the cardiovascular safety of tadalafil when prescribed in primary care in England: mortality due to ischaemic heart disease. BJU International 99:2, 387-393
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Gregory D. Lewis, Christian Witzke, Pedro Colon-Hernandez, J. Luis Guerrero, Kenneth D. Bloch, Marc J. Semigran. (2006) Sildenafil Improves Coronary Artery Patency in a Canine Model of Platelet-Mediated Cyclic Coronary Occlusion After Thrombolysis. Journal of the American College of Cardiology 47:7, 1471-1477
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J. Frantzen, T.G.W. Speel, L.A. Kiemeney, E.J.H. Meuleman. (2006) Cardiovascular Risk Among Men Seeking Help for Erectile Dysfunction. Annals of Epidemiology 16:2, 85-90
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A. Boshier, L.V. Wilton, S.A.W. Shakir. (2004) Evaluation of the safety of sildenafil for male erectile dysfunction: experience gained in general practice use in England in 1999. BJU International 93:6, 796-801
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M.L. Iglesias, C. Jericó, E. Skaf, J. Pedro-Botet. (2003) Sildenafil and coronary artery disease. BJU International 92:7, 824-825
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Bodo Cremers, Marina Scheler, Christoph Maack, Olaf Wendler, Hans-Joachim Schäfers, Michael Südkamp, Michael Böhm. (2003) Effects of Sildenafil (Viagra) on Human Myocardial Contractility, In Vitro Arrhythmias, and Tension of Internal Mammaria Arteries and Saphenous Veins. Journal of Cardiovascular Pharmacology 41:5, 734-743
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Zhenyu Li, Xiaodong Xi, Minyi Gu, Robert Feil, Richard D. Ye, Martin Eigenthaler, Franz Hofmann, Xiaoping Du. (2003) A Stimulatory Role for cGMP-Dependent Protein Kinase in Platelet Activation. Cell 112:1, 77-86
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Geoffrey I. Hackett. (2002) What Do Patients Expect from Erectile Dysfunction Therapy?. European Urology Supplements 1:8, 4-11
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A. L. McLeod, C. J. McKenna, D. B. Northridge. (2002) Myocardial infarction following the combined recreational use of viagra® and cannabis. Clinical Cardiology 25:3, 133-134
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P.C. Souverein, A.C.G. Egberts, M.C.J.M. Sturkenboom, E.J.H. Meuleman, H.G.M. Leufkens, J. Urquhart. (2001) The Dutch cohort of sildenafil users: baseline characteristics. BJU International 87:7, 648-653
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HANA YOON, DONG SUK KIM, JI SUK LIM, WOO SIK CHUNG, YOUNG YO PARK. (2001) INTRACAVERNOSAL INJECTION OF SILDENAFIL CITRATE: MISAPPLICATION OF THE DRUG. The Journal of Urology1218-1219
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HANA YOON, DONG SUK KIM, JI SUK LIM, WOO SIK CHUNG, YOUNG YO PARK. (2001) INTRACAVERNOSAL INJECTION OF SILDENAFIL CITRATE: MISAPPLICATION OF THE DRUG. The Journal of Urology 165:4, 1218-1219
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E Boyce. (2001) Sildenafil citrate: A therapeutic update. Clinical Therapeutics 23:1, 2-23
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John P. Pryor. (2000) Safety of sildenafil. Current Opinion in Urology 10:6, 613-615
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Herrmann, Howard C., Chang, Gene, Klugherz, Bruce D., Mahoney, Paul D., . (2000) Hemodynamic Effects of Sildenafil in Men with Severe Coronary Artery Disease. New England Journal of Medicine 342:22, 1622-1626
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(2000) Current Awareness. Pharmacoepidemiology and Drug Safety 9:1, 75-90
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&NA;. (1999) Nitroglycerin/sildenafil. Reactions Weekly &NA;:767, 10
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