American Journal of Emergency Medicine 31 (2013) 1424.e1-1424.e3

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American Journal of Emergency Medicine

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Case Report

The relationship between acute coronary syndrome and sildenafil

Abstract

Sildenafil is a drug used for male Erectile dysfunction. Sildenafil’s fatal Cardiac effects except due to hypotension with simultaneous nitrate use have not been reported. We reported in this case a 70-year- old man admitted to the emergency service with chest pain, which occurs in an hour after sildenafil use. Electrocardiogram showed inferoposterior ST-segment elevation. In angiography, total circumflex artery occlusion has been seen.

Sildenafil citrate is widely used as a primary pharmacological treatment of erectile dysfunction in men with and without underlying cardiovascular disease [1]. A large body of data suggests that sildenafil does not significantly increase the risk of nonfatal myocardial infarction (MI), stroke, or cardiovascular deaths in patients with preexisting ischemic heart disease [2,3]. We report a case of 70-year-old man who developed thrombotic occlusion of circumflex artery (Cx) and presented with acute MI after the use of sildenafil.

A 70-year-old male patient presented to our emergency department with chest pain for 1 hour after taking 100 mg sildenafil citrate before any attempted Sexual activity. He has a history of hypertension and smoking. There was no history of other systemic disease. The patient’s blood pressure was 90/60 mm Hg, and heart rate was regular, with 110 beats per minute. Initial electrocardio- gram showed ST-segment elevation over lead II, III, aVF, and posterior leads (Fig. 1A-C). The patient immediately underwent a coronary angiography. Emergent percutaneous coronary interven- tion was done. Coronary angiography showed total occlusion in Cx just below the first marginal branch (Fig. 2). Balloon predilatation and drug-eluting stent (2.5 x 30 mm endeavor) implantation were performed after 45 minutes of admission (Fig. 3A and B). After percutaneous coronary intervention, ST-segment elevations in all leads resolved and chest pain relieved immediately. Medical treatment started with acetylsalicylic acid, clopidogrel, atorvastatin, metoprolol, angiotensin-converting enzyme inhibitors, and proton- pump inhibitor. The patient was discharged after 5 days of hospitalization with medical therapy.

Sildenafil reduces blood pressure modestly via relaxing vascular smooth muscle. This reduction is insufficient to stimulate a reflex increase in heart rate. Sildenafil does not affect the contractility but mildly vasodilates the coronary arteries. It has no negative effects on coronary oxygen consumption, ischemia, or exercise capacity and does not increase the risk of ventricular arrhythmia [1].

In contrast, sildenafil-associated MI is rarely seen in patients without previous history of coronary artery disease [2]. Feenstra et al [4] reported the first case of sildenafil-associated MI in a patient with no known cardiac history. The authors advocated that

redistribution of arterial blood flow may reduce coronary perfusion and lead to MI [4]. Currently, a few cases have been published regarding sildenafil-associated MI in the absence of known cardiac history [5-7]. Aterosclerotic critical occlusion was demonstrated by coronary angiography, but total coronary thrombosis was not seen in these cases. Only 2 cases have been published presenting acute coronary thrombosis after using sildenafil [7,8]. They reported the case of a 66-year-old man who developed thrombotic total occlusion of left anterior descending coronary artery and presented with acute MI after using of sildenafil. Their patient presented with chest pain a week before using sildenafil, and an angiogram had demonstrated Normal coronary arteries [8]. Other case was a 43- year-old man who develop thrombotic occlusion of left anterior descending coronary artery and presented with acute MI after the use of sildenafil [7].

This report shows a rare sildenafil-associated acute thrombotic occlusion and MI in a patient without previous history of coronary artery disease. Further studies and data are needed to prove the association between sildenafil intake and acute coronary syndrome.

Ismail Ekinozu MD Yusuf Aslantas MD Hakan Tibilli MD Yasin Turker MD Hakan Ozhan MD

Department of Cardiology, Faculty of Medicine

Duzce University, Duzce, Turkey E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.05.019

References

1. Jackson G, Montorsi P, Cheitlin MD. Cardiovascular safety of sildenafil citrate (Viagra); an updated perspective. Urology 2006;68:47-60.
2. Mittleman MA, Glasser DB, Orazem J. Clinical trials of sildenafil citrate (Viagra) demonstrate no increase in risk of myocardial infarction and cardiovascular death compared with placebo. Int J Clin Pract 2003;57:597-600.
3. Kontaras K, Varnavas V, Kyriakides ZS. Does sildenafil cause myocardial infarction or sudden cardiac death? Am J Cardiovasc Drugs 2008;8:1-7.
4. Feenstra J, Van Drie-Pierik RJ, Lacle CF, Stricker BH. Acute myocardial infarction associated with sildenafil. Lancet 1998;352(9132):957-8.
5. Hayat S, Al-Mutairy M, Zubaid M, Suresh C. Acute myocardial infarction following sildenafil intake in a nitrate-free patient without previous history of coronary artery disease. Med Princ Pract 2007;16(3):234-6.
6. Kekilli M, Beyazit Y, Purnak T, Dogan S, Atalar E. Acute myocardial infarction after sildenafil citrate ingestion. Ann Pharmacother 2005;39(7-8):1362-4 [Epub 200].
7. Tatli E, Cakar MA, Dogan E, Alkan M. Does sildenafil contribute to acute coronary thrombosis? Turk Kardiyol Dern Ars 2012;40(6):536-9.
8. Saha SA, O’Cochlain B, Singh A, Khosla S. Sildenafil-associated coronary thrombosis in a patient with angiographically normal coronary arteries: a case report with review of literature. Am J Ther 2006;13:378-84.

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   Fig. 1. A to C, Electrocardiogram indicating acute inferoposterior MI.

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   Fig. 2. Right caudal view coronary angiogram demonstrating thrombotic occlusion of the left Cx artery and the presence of a thrombus in the Cx artery.

   Fig. 3. A and B, Last angiogram of the Cx artery after Balloon angioplasty and stenting.