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Are erectile dysfunction pills safe for men with heart disease?

In men without cardiovascular disease, erectile dysfunction pills are very safe. The three rivals -- Viagra, Cialis, and Levitra -- have similar side effects, including headache, facial flushing, nasal congestion, diarrhea, backache, and, in a few Viagra or Levitra users, temporary impaired color vision (men with retinitis pigmentosa, a rare eye disease, should check with their ophthalmologists before using these medications).

Headaches and blue vision are one thing, cardiac abnormalities, quite another. Are ED pills safe for the heart?

These drugs are safe for healthy hearts, but all men with cardiovascular disease should take special precautions, and some cannot use them under any circumstances. The problem is their effect on arteries. All arteries, not just those in the penis, generate nitric oxide, so any artery can widen in response to Viagra, Levitra, or Cialis, causing blood pressure to drop temporarily by 5-8 mmHg, even in healthy men.

Organic nitrates are drugs that widen arteries by increasing their supply of nitric oxide; that’s how they open the partially blocked coronary arteries in patients with angina. But because nitrates and ED pills both act on nitric oxide, the drugs don’t mix; healthy volunteers given Viagra followed an hour later by nitroglycerin see their blood pressures drop by 25–51 mm Hg, a potentially dangerous amount. All experts agree that men who are taking nitrates cannot use ED pills; this includes all preparations of nitroglycerin (short-acting, under-the-tongue tablets or sprays), long-acting nitrates (isosorbide dinitrate or Isordil, Sorbitrate, and others, and isosorbide mononitrate, Imdur, ISMO, and others), nitroglycerin patches and pastes, and amyl nitrite or amyl nitrate (so-called poppers, which some men use for sexual stimulation). Men who have taken Viagra or Levitra must not take nitrates for 24 hours; for Cialis, the ban extends to 48 hours, a disadvantage for men at risk for heart disease.

Faced with concern about ED pills and the heart, the FDA has urged caution in patients who have suffered heart attacks, strokes, or serious disturbances of the heart’s pumping rhythm in the previous six months, in men with a history of congestive heart failure or unstable angina, and in men with low blood pressure or uncontrolled high blood pressure (above 170/110 mm Hg). Because certain medications can boost the blood levels of these drugs, men taking erythromycin or certain antifungal or anti-HIV medications should use only low-dose PDE-5 inhibitors. Reduced dosage is also important for men with advanced age and for those with significant kidney or liver disease.

Faced with all these warnings, should any man use Viagra, Levitra, or Cialis? Indeed, no one should use them needlessly or recklessly, but 20 million American men are plagued by impotence, and most can use them safely.

If nothing can be done to correct the cause of a man’s erectile dysfunction and if he has no problems that make oral medications risky, then a drug is worth a try. Each comes in several strengths; most doctors prescribe a middle dose initially, lowering it if it works well or increasing it if it does not. Men with potential problems should always start with the lowest dose. Every man should avoid consuming alcohol before taking these drugs. Men who do not respond to a full dose on two or three different occasions should try other treatments.

July 2005 Update

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