Cialis or Viagra Taken With Chest Pain Drugs May Raise Risk of Early Death

Men with coronary artery disease who take erectile dysfunction drugs along with nitrates, a common treatment for chest pain, face a significantly higher likelihood of dying early, according to a study published this week in the Journal of the American College of Cardiology.

In addition to a greater death risk, the combined use of nitrates with phosphodiesterase type 5 (PDE5) inhibitors, such as Viagra, Levitra, and Cialis, was linked with an increased risk of heart failure, heart attack, and revascularization (procedures to improve blood flow to the heart) compared with taking nitrates alone.

“Physicians are seeing an increase of requests for erectile dysfunction drugs from men with cardiovascular diseases,” said senior study author Daniel Peter Andersson, MD, an associate professor of physiology at Karolinska Institutet in Stockholm, in a statement. “While there is a positive association of ED medication for men with cardiovascular disease, patients taking nitrates may experience an increased risk of negative health outcomes.”

RELATED: Viagra and Cialis May Cut Risk of Early Death From Heart Disease by 25 Percent

The new research involved more than 61,000 men in Sweden with a history of heart attack or percutaneous coronary intervention (a procedure to open blocked arteries) who had received two nitrate prescriptions within six months. In total, 55,777 men were treated with nitrates and 5,710 men with nitrates and an ED drug.

The average follow-up time was 5.7 years for nitrate-only users and 3.4 years for those with the combined treatment. Overall, those taking nitrates and drugs for erectile dysfunction were younger — 61.2 years old on average, compared with 70.3 years old for the nitrate-only users.

Results indicated that men taking nitrates along with ED meds had a 39 percent higher risk of dying compared with those on nitrates alone. That group also faced a 72 percent increased likelihood of heart attack, a 67 percent higher risk of heart failure, and 95 percent higher odds of needing revascularization.

A Combination That Can Trigger a Sharp Drop in Blood Pressure

The potential health hazards from taking nitrates along with erectile dysfunction medications are not entirely surprising. The U.S. Food and Drug Administration has warned that Viagra may interact with nitrates found in some prescription drugs, such as nitroglycerin, and may lower blood pressure to dangerous levels. People with diabetes, high blood pressure, high cholesterol, or heart disease often take nitrates, which dilate the blood vessels.

“This study just emphasizes the fact that PDE5 inhibitors remain a contraindication when a person is also taking nitrates,” says Robert Kloner, MD, PhD, the director of the Cardiovascular Research Institute at Huntington Medical Research Institutes in Pasadena, California, and a professor of medicine in the cardiovascular division at the Keck School of Medicine of USC.

A contraindication is a situation in which a particular drug should not be used because it could be harmful to the patient.

Although the most recent study found PDE5 inhibitor drugs contraindicated for men who take nitrates, Dr. Kloner notes that some previous research has suggested that some men who take this combination may not experience an increase of cardiac events.

“The current study shows contrary effects and there are some potential reasons for it,” he says. “This new study is already in a high-risk population of men who have either had myocardial infarctions [heart attacks] or percutaneous coronary interventions.”

Taking a Cautious and Educated Approach When Combining Meds

Kloner adds that patients in previous research may have had more education from their healthcare providers not to take the two types of drugs at the same time.

“If a man takes a PDE5 inhibitor, has sexual activity and gets angina [chest pain], he should not pop a sublingual nitroglycerin tablet within 24 hours of using a short-acting PDE5 inhibitor or within 48 hours if it is a long-acting PDE5 inhibitor,” he says.

The study highlighted that few heart events occurred 28 days after dispensing the PDE5 inhibitors, with lower incidence rates than in men who only took nitrates.

Kloner recommends that if a man is on nitrates but wants to try PDE5 inhibitors for treating ED, he should discuss this with his healthcare provider. He points out that alternatives to nitrates for treating angina are available, and some patients who have had heart trouble may no longer need to be on nitrates.

In an editorial comment accompanying the study, Glenn N. Levine, MD, with the Baylor College of Medicine and the Michael E. DeBakey VA Medical Center in Houston, wrote that erectile dysfunction medications should be reasonably safe to take for patients with ischemic heart disease, only mild angina, and with reasonable exercise ability — if the patient is not on chronic nitrate therapy.

For those on chronic oral nitrate therapy, however, use of drugs like Viagra and Cialis is ill-advised at best and generally contraindicated, he stressed.

“Erectile dysfunction and coronary artery disease are unfortunate, and all too common, bedfellows,” wrote Dr. Levine. “But, as with most relationships, assuming proper precautions and care, they can coexist together for many years, perhaps even a lifetime.”