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3) Patients not using long-acting nitrates but requiring nitrates sublingual for treatment of episodes of angina should be informed about the hazarg of using sildenafil, unless the nitrate

can

5) High-risk cardiovascular patients, including patients with atherosclerotic disease, NYHA functional classes II and III patients individuals above 65 years of age, hypertensive and, diabetic

patients

the

6) High-risk cardiovascular patients should be previously assessed through a treadmill stress test.

The risk of ischemia during coitus is low if they do not develop clinical or electrocardiographic signs, of ischemia and or arrhythmia, until a load of 5 to 6 METs is reached. These load limits are valid for coitus with the usual partner, in a familiar environment, and without additional overload of excessive consumption of food and alcoholic beverages. Patients without sexual activity for a long period should be advised to moderate their physical activity and anxiety during their return to sexual activity.

7) In patients without ischemia and or arrhythmia, or both, on the treadmill stress test with load lower than 5 to 6 METs, the use of sildenafil should be conditioned to the clinical situation of the patient.

8) It is convenient that patients using vasodilators and diuretics simultaneously should be monitored for a hypotensive response to sildenafil. 9) Physicians and allied health personal emergency departments should be instructed to routinely ask patients about the use of sildenafil. 10) Patients using sildenafil should be instructed to tell about the use of sildenafil in case of an emergency. 11) An initial dose of 25 mg should be recommended in all situations that may increase the plasma concentration of sildenafil or potentiate its vasodilating effect and that do not constitute a formal contraindication for its use. Treatment of acute ischemic syndromes in patients using sildenafil. Initial treatment of the precordial pain suspicious of angina ? Carefully identify when the last dose of sildenafil was taken.

Do not use any type of nitrate if sildenafil has been taken within the preceding 24 hours.

From 24 to 48 hours after use of sildenafil, nitrate may be administered if no associated conditions increasing plasma concentration or delaying metabolism of sildenafil, such as age above 65 years, severe renal or hepatic failure, or simultaneous use of inhibitors of cytochrome P450 3A4, exist. In such instances, nitrates should only be used if conditions for the treatment of a possible

severe

For the treatment of precordial pain no data about drug interactions are available contraindicating the use of sildenafil with aspirin, beta-blockers, calcium channel antagonists, or narcotics.

Patients with acute myocardial infarction ? The same previous precautions should be taken. So far, no restraints regarding the use of heparin, cumarin, and thrombolytic agents exist. In the case of hypotension, recovery of proper pressure levels pfizer online store can hinder the progression of myocardial lesions.

Unstable angina ? The same guidelines and warnings in relation to the use of nitrates and other medications commonly used in the treatment of this condition apply.

Treatment of the hypotension resulting from the interaction of sildenafil with nitrates.

The following measures should be employed in sequence: 1) place the patient in the Trendelenburg's position; 2) administer intravenous fluids rapidly; 3) use intravenous alpha-adrenergic agonists, such as phenylephrine, ethylephrine, or metaraminol; 4) if necessary, use an alpha or beta agonist, such as norepinephrine to support blood pressure, but one should be aware of the risk of worsening or inducing

myocardial

The recommendations here expressed result from a still limited experience in regard to some of the multiple clinical situations of patients with cardiovascular disease, who intend to use sildenafil. Therefore, the risk in face of these not yet tested situations is presumed based on what is known in regard to the pharmacokinetics and pharmacodynamics of the medication.

This can be applied to situations such as heart failure, the first 6 months after an acute myocardial infarction or after a stroke, and uncontrolled hypertension, which are situations absent in the published studies. In addition, some other pending questions should be remembered due to their importance and to a better comprehensiveness of this study: a) interaction with platelet antiaggregating agents other than aspirin; b) interaction with other phosphodiesterase inhibitors, including specific (milrinone, vesnarinone, enoximone) and nonspecific (theophylline, dipyridamole, papaverine, and pentoxifylline) inhibitors; c) effects of sildenafil on the central nervous system (PDE5 is present in the brain); d) the isolated hypotensive effect of sildenafil in high-risk patients with heart disease (severe heart failure); e) effect on skeletal muscles (thoracic muscle pains that may be mistaken for angina); f) simultaneous use of alcoholic beverages, especially with antihypertensive agents.

Sildenafil has proved to be an effective and well-tolerated medication; these characteristics may be extended to patients with ischemic heart disease.

Therefore, the number of patients with cardiovascular disease willing to try the drug has been increasing. These patients, however, have two potential risks in relation to the use of sildenafil.

The first is an indirect risk and relates to the ability to accomplish coitus, which is an activity associated with an increase in energy consumption and with varied degrees of psychological stress. The second is the risk of developing severe hypotension, which is directly linked to sildenafil-nitrate interaction. In such circumstances, it is up to the cardiologist to decide and guide the patient in regard to the safe use of sildenafil. This study, based on the existing scientific data, on recommendations of a working group of the American College of Cardiology and of the American Heart Association, and on our initial experience, aims to provide to physicians in general and more specifically to cardiologists the necessary information so that sildenafil can be used as safely as possible in patients with cardiovascular disease.

Sociedade Brasileira de Urologia - I Consenso Brasileiro de Disfuncao Eretil. Does severity of ischemic coronary diseasecorrelate with erectile dysfunction?

Muller JE, Mittelman MA, Maclure M, Sherwood JB, Tofler GH. Triggering miocardial infarction by sexual activity - low absolute risck and prevention by regular physical exertion. Sexual activity triggering miocardial infarction - one less thing to worry about. Oral sidenafil in the treatment of erectile dysfuncion. Morales A, Gingell C Collins M, Wicker PA, Osterloh IH. Clinical safety of oral citrate (VIAGRA) in the treatment of erectile dysfunction.

Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB.

Impotence and its medical and psychosocial correlates: results of the Massachusets male aging study. Sildenafil: na orally active

type

Potencial roles of conserved amino acids in the catalic domain of the cGMP-binding cGMP-specific phosphodiesterase (PDE5).

Use of sildenafil (Viagra) in patients with cardiovascular disease.

[ Links ] Forca-Tarefa para o Uso do Sildenafil e Doencas Cardiovasculares (Task Force for the Use of Sildenafil and Cardiovascular Diseases) Mailing Adress: Armenio Costa Guimaraes - Av. Garibaldi, 1555 - 40210-070 - Salvador, BA - Brazil. All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License. Marechal Camara, 160 - 3? Andar - Sala 330 20020-907, Centro, Rio de Janeiro, RJ - Brazil Tel.: +55 21 3478-2700 Fax: +55 21 3478-2770. About sildenafil Key facts Who

can

It increases blood flow to the penis to help men get an erection. At least two-thirds of men have improved erections after taking it.

Sildenafil is also sometimes used to treat pulmonary hypertension (high blood pressure in the blood vessels that supply the lungs). This medicine is available on prescription and can also be bought from most pharmacies.

It comes as tablets that you swallow, chewable tablets, and as a liquid that you drink.

It usually takes 30 to 60 minutes for sildenafil to work for erectile dysfunction. You can take it up to 4 hours before you want to have sex. Taking sildenafil alone will not cause an erection. The most common side effects are headaches,

feeling

It can be dangerous to take sildenafil if you also take medicines called nitrates (often given for chest pain).

The combination can cause a dangerous fall in your blood pressure. If you're not sure if you're taking a nitrate, ask your doctor or pharmacist. Sildenafil is

called

Sildenafil for erectile dysfunction (Viagra) can be taken by men aged 18 and over.

Sildenafil for pulmonary hypertension (Revatio) can be taken by adults and children aged 1 and over.

Do not take sildenafil if you: have had an allergic reaction to sildenafil (Viagra) or any other medicines in the past are taking medicines called nitrates for chest pain have a serious heart or liver problem have

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