Article, Cardiology

Acute coronary syndrome and sildenafil – coincidence or coexistence: Author reply


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American Journal of Emergency Medicine

journal homepage: www. locate/ajem

Acute coronary syndrome and sildenafil–coincidence or coexistence

To the Editor,

We read the article by Ekinozu et al [1] with great interest. Based on the temporal relationship between ingestion of sildenafil and the onset of chest pain, the authors concluded sildenafil as a cause for acute coronary syndrome, which is not congruent with current evidence [2]. Sildenafil does not reduce the Coronary blood flow in either diseased or Normal coronary arteries. Indeed, data from animal and human studies undoubtedly have shown that sildenafil increases coronary blood flow during exercise even in coronary arteries, which has critical stenosis, thus, results in an improvement in the epicardial flow and thereby averts the effects of myocardial ischemia [3,4].

Herrmann et al [5] documented significant increase in coronary flow reserve in both stenosed and reference arteries within 45 minutes after taking 100 mg of sildenafil orally in contrast to baseline value, suggesting that sildenafil is unlikely to cause coronary steal. Sildenafil has proven to be effective, safe, and well tolerated in coronary artery disease (CAD) patients [6]. The patient described in the report [1] had Erectile dysfunction, which required sildenafil to maintain a penile erection sufficient to perform sexual act. Recent studies indicate that erectile dysfunction is a harbinger of CAD, as atherosclerosis, a systemic disease, affects both coronary and penile vasculature. Montorsi et al [7] had mentioned that erectile dysfunc- tion may be the “tip of the iceberg” of a systemic vascular disorder. Blumentals et al [8] found that men with erectile dysfunction had a 2- fold increase in the risk for acute myocardial infarction after adjusting for age, smoking, hypertension, and obesity. The risk is greater with increasing age as observed in this case.

Moreover, American College of Cardiology/American Heart Asso- ciation consensus opines that sildenafil is safe for patients with Stable CAD who are not taking nitrates [9]. Further individual’s independent risk factors such as his age, sex, smoking habit, and hypertension might have also contributed to the onset of acute coronary syndrome. Therefore, we conclude that emotional stimulation associated with anticipated Sexual activity in this high-risk patient might have triggered rupture of vulnerable coronary plaque rather than accusing the sildenafil. Before embarking definitive statements, let us consider coexisting risk factors than attributing to coincidence.

Subramanian Senthilkumaran MD Department of Emergency and Critical Care Sri Gokulam Hospital and Research Institute

Salem, Tamil Nadu, India E-mail address: [email protected]

Namasivayam Balamurugan MD, DM

Department of Neurosciences

Manipal hospital Salem, India

Ramachandran Meenakshisundaram MD Ponniah Thirumalaikolundusubramanian MD

Department of Internal Medicine Chennai Medical College Hospital and Research Center

Irungalur, Trichy, Tamil Nadu, India


  1. Ekinozu I, Aslantas Y, Tibilli H, Turker Y, Ozhan H. The relationship between acute coronary syndrome and sildenafil. Am J Emerg Med 2013;31:1424.e1-3.
  2. Raja SG, Nayak SH. Sildenafil: emerging cardiovascular indications. Ann Thorac Surg


    Przyklenk K, Kloner RA. Sildenafil citrate (Viagra) does not exacerbate myocardial ischemia in Canine models of coronary artery stenosis. J Am Coll Cardiol 2001;37:286-92.

  3. Gillies HC, Roblin D, Jackson G. Coronary and systemic hemodynamic effects of sildenafil citrate: from basic science to clinical studies in patients with cardiovascular disease. Int J Cardiol 2002;86:131-41.
  4. Herrmann HC, Chang G, Klugherz BD, Mahoney PD. Hemodynamic effects of sildenafil in men with severe coronary artery disease. N Engl J Med 2000;342:1622-6.
  5. DeBusk RF, Pepine CJ, Glasser DB, Shpilsky A, DeRiesthal H, Sweeney M. Efficacy and safety of sildenafil citrate in men with erectile dysfunction and stable coronary artery disease. Am J Cardiol 2004;93:147-53.
  6. Montorsi P, Montorsi F, Schulman CC. Is erectile dysfunction the “Tip of the Iceberg” of a systemic vascular disorder? Eur Urol 2003;44:352-4.
  7. Blumentals WA, Gomez-Caminero A, Joo S, Vannappagari V. Should erectile dysfunction be considered as a marker for acute myocardial infarction? Results from a retrospective cohort study. Int J Impot Res 2004;16:350-3.
  8. Cheitlin MD, Hutter Jr AM, Brindis RG, Ganz P, Kaul S, Russell Jr RO, et al. ACC/AHA expert consensus document: use of sildenafil (Viagra) in patients with cardiovas- cular disease. American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999;33:273-382.

    Acute coronary syndrome and sildenafil – coincidence or coexistence: Author reply

    To the Editor,

    We thank our colleagues for their interest in our manuscript. They claimed our conclusion is a definite statement. Let us except their concerns on age, sex, smoking habit, and hypertension. However, the patient had a Naranjo score of 4/16 indicating a probable cause-and- effect relationship between sildenafil and acute coronary syndrome [1]. Of course, our case does not establish a definite correlation between sildenafil use and myocardial infarction, but cumulative reports showed that there is more than a coincidence. Furthermore, Li et al [2] showed that sildenafil potentiated thrombin-induced platelet aggregation in vitro when the proaggregatory stimulus was given within 10 minutes of sildenafil exposure. We believe that every clinician should suspect and report possible drug reactions for safety of our patients.

    0735-6757/$ – see front matter (C) 2013

    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]


    Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA, et al. A method for estimating the probability of Adverse drug reactions. Clin Pharmacol Ther 1981;30:239-45.

  9. Li Z, Xi X, Gu M, Feil R, Ye RD, Eigenthaler M, et al. A stimulatory role for cGMP- dependent protein kinase in platelet activation. Cell 2003;112(1):77-86.

    The relationship between in-hospital mortality and preexisting medications in geriatric trauma patients?

    To the Editor,

    We read the article “Evaluation of geriatric patients with trauma scores after Motor vehicle trauma” by Cevik et al [1] with interest. The authors aimed to investigate the factors affecting in-hospital mortality among geriatric trauma patients who presented to the emergency department (ED) after a motor vehicle collision. They concluded that heart failure, cranial trauma, abdominal trauma, pelvic trauma, and Injury Severity Score are strong and independent predictors of in- hospital mortality among this target study population.

    Geriatric patients account for 23% of all trauma admissions to ED, and trauma is the fifth leading cause of death in patients older than 65 years. The Geriatric population is unique in the type of traumatic injuries sustained and physiological responses to those injuries. There are some differences in the normal physiology of geriatric patients that will make their evaluation and treatment more challenging [2-4]. On the other hand, the number of comorbidities generally is higher in this population, and this appears to contribute directly to poorer outcomes. More than 50% of the geriatric trauma population has underlying hypertension, and more than 30% have heart disease. In addition, the increased use of multiple pharmaceutical agents is associated with the high rate of comorbidities. The Psychotropic medications (antidepressants, neuroleptics, and sedatives), ?-blockers, antiplatelet medications (aspirin or clopidogrel), and anticoagulants, especially warfarin, are important drug classes that make management of the geriatric trauma patient more difficult. The ?-blockers may mask Abnormal vital signs, which can further confound the primary survey. The widespread use of anticoagulants and Antiplatelet agents in the elderly

    population may bleed more rapidly from relatively minor injuries [5]. Ferraris et al [2] found that presence of congestive heart failure,

    particularly in patients who take ?-blockers or warfarin, can confer a 5- to 10-fold increased risk of death following trauma. They also emphasized the importance of preinjury medications history in geriatric trauma patients [2]. Neideen et al [6] studied injured patients older than 65 years admitted to level 1 trauma center. They found that, in patients without head trauma, preinjury ?-blockade had a significant association with mortality (odds ratio, 2.1; confidence interval, 1.1-4.3), and mortality in patients with head trauma was

    25.9%, significantly associated with warfarin use (odds ratio, 2.5; 95% confidence interval, 1.3-4.8) [6].

    Consequently, all currently prescribed, over-the-counter, and herbal medications history should be obtained and recorded for comprehensive assessments in all geriatric trauma patients. In addition, analysis of the drug-Drug interaction, adverse drug events, and drugs considered inappropriate for the elderly patients must be part of the evaluation of the future geriatric trauma clinical trials.

    Yalcin Golcuk MD Murat Ozsarac MD Celal Bayar University

    Faculty of Medicine, Department of Emergency Medicine

    Manisa, Turkey E-mail address: [email protected]

    Burcu Golcuk MD Merkez Efendi State Hospital Department of Clinical Biochemistry

    Manisa, Turkey

    Yalcin Velibey MD Bitlis State Hospital Department of Cardiology

    Bitlis, Turkey

    Salahaddin Akcay MD

    Celal Bayar University Faculty of Medicine, Department of Cardiology

    Manisa, Turkey


    Cevik Y, Dogan NO, Das M, et al. Evaluation of geriatric patients with trauma scores after motor vehicle trauma. Am J Emerg Med 2013;31:1453-6.

  10. Ferraris VA, Ferraris SP, Saha SP. The relationship between mortality and preexisting cardiac disease in 5,971 trauma patients. J Trauma 2010;69:645-52.
  11. Thompson HJ, McCormick WC, Kagan SH. Traumatic brain injury in older adults: epidemiology, outcomes, and future implications. J Am Geriatr Soc 2006;54: 1590-5.
  12. Keller JM, Sciadini MF, Sincalir E, et al. Geriatric trauma: demographics, injuries and mortality. J Orthop Trauma 2012;26:e161-5.
  13. Aschkenasy MT, Rothenhaus TC. Trauma and falls in the elderly. Emerg Med Clin North Am 2006;24:413-32.
  14. Neideen T, Lam M, Brasel KJ. Preinjury Beta blockers are associated with increased mortality in geriatric trauma patients. J Trauma 2008;65:1016-20.

    ED antibiotic use in a developing country?


    Antibiotics are frequently started in emergency departments (EDs). Several studies performed in developed countries evaluated the quality of antibiotic use in these departments [1,2]. No data appraising antimicrobial practice in EDs are available in Developing countries. The aims of the study were to evaluate anti-infective treatments initially delivered to patients hospitalized in an ED in Morocco and to define factors impairing the appropriateness of these prescriptions.


    Prospective observational prevalence study conducted during 3 months (March to June 2011) in the ED of a tertiary care hospital in

    ? Competing interests: The authors declare that they have no commercial

    associations or sources of support that might pose a conflict of interest. ? Conflict of interest: None.

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