Older men on PDE-5 inhibitors after acute myocardial infarction: Reduction of mortality and risk of heart failure

After having a first myocardial infarction, men who filled at least one prescription for a drug to treat erectile dysfunction had a 33% lower risk of dying and a 40% lower risk of hospitalization for heart failure (HF) during one follow-up of 3 years, compared with other men, in a Swedish study registry.

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These better results were seen only with phosphodiesterase-5 (PDE-5) inhibitors, not alprostadil, and appeared to be dose dependent and were significant only in older men, 70-80 years.

However, the results “should be interpreted with caution,” emphasized Dr. Daniel P Andersson (Karolinska Institutet, Stockholm, Sweden) at a press conference before a poster session at the American College of Cardiology (ACC) 2017 Scientific Sessions . The study was also published simultaneously online at Heart.

It was an observational study, so it can not show cause and effect, and it was not known whether the men who received the drugs with erectile dysfunction were less depressed, more physically active or happier.

Therefore, the study “is more hypothesis generation than a clear statement that all subjects [who have had a MI] must have a PDE-5 inhibitor,” Andersson told heartwire of Medscape.

Physicians should follow ACC / AHA guidelines for prescribing PDE-5 inhibitors (including non-nitrates) and make a patient risk assessment, but this study suggests that if a patient who has had an MI has none Contraindication “It is likely to be safe to prescribe [a PDE-5 inhibitor], and this person is more likely to survive longer,” he said.

Lead author Dr. Martin J Holzmann (Karolinska Institute) agreed, but was even more convinced by the strength of the findings.

“It’s a huge risk reduction … very surprising,” and contrary to its original hypothesis, he told heartwire. On the other hand, “in clinical epidemiology, if you have a relationship with a 40% risk reduction or a 33% risk reduction, there is no residual confusion that will change to zero.”

“We have patients who have erectile dysfunction, … who are diabetic and … have heart disease, and the question is whether it is safe to put them on a phosphodiesterase inhibitor or not,” said Dr. Amit Tibrewala Northside, Atlanta, Georgia), who did not participate in this study, he told heartwire.
If a patient “can get on the tape and operate at a reasonable speed, then even after myocardial infarction I feel comfortable” prescribing a PDE-5 inhibitor, he continued, “obviously, we tell them not to use it together with A Nitrate. ”

They analyzed the registry data of 43,145 men aged 18 to 80 years who were hospitalized for a first MI during 2007-2013 in Sweden.
The drugs available to treat erectile dysfunction at that time were the three oral PDE-5 inhibitors sildenafil (Viagra, Pfizer), tadalafil (Cialis, Lilly / ICOS) and vardenafil (Levitra, Bayer / GlaxoSmithKline) and prostaglandin alprostadil injection .

Only 7% of men filled a prescription for erectile dysfunction medication (for a PDE-5 inhibitor in 92% of cases), demonstrating that there was “definitely sub-treatment,” Holzmann said.

At the baseline, men who filled a prescription for an erectile dysfunction drug were younger (mean age 61 vs. 64) and less likely to have diabetes (10% vs 13%), heart failure (0.6% vs. 2.1% (3% vs 6%)) or active cancer (0.8% vs. 1.3%) or taking nitrates (3.5% vs. 5.7%). Compared with other men, fewer men who received erectile dysfunction treatment died (3.7% vs 12%) or were hospitalized for HF (1.4% vs. 6.0%) during follow-up.
After adjusting for differences in baseline comorbidities and drug use, compared with men who did not fill a prescription for an erectile dysfunction drug, those who had a lower risk of death from all causes (HR 0.67 , 95% CI 0.55-0.81) and hospitalization for heart failure (HR 0.60, 95% CI 0.44-0.82).

They also had a lower risk of non-cardiovascular death or cardiovascular death but had a similar risk for new MI or need for revascularization during follow-up.
The risk of death during follow-up decreased steadily in men who received one, two to five, or more than five prescriptions for a PDE-5 inhibitor, but this finding is just the generating hypothesis, the researchers caution.

Men who were 70-80 had a 59% lower risk of death during follow-up if they were taking erectile dysfunction drugs than if they were not taking these drugs. However, younger men had a similar rate of death, whether they were taking drugs with erectile dysfunction.

Set of scenarios for further investigation

“I’m a bit worried about the message that all of a sudden these medications can safely be administered to anyone who has had a previous heart attack,” said press conference moderator Dr. Martha Gulati (University of Arizona, Phoenix ).

“You can interpret our results as if you have an active sex life after a heart attack and ask your doctor for a PDE-5 inhibitor, and if you are 70 years old and otherwise healthy” it is probably safe to use A PDE-5 inhibitor, Andersson said.

The researchers plan to conduct a larger study with data on socioeconomic status, marital status and education.

The study was funded by the Stockholm County Council and the Swedish Heart and Lung Foundation.