1. Sildenafil detected significant coronary artery stenosis
Hanil General Hospital
Seoul, Korea
Ji Yeon Hong ㅁ

2. Disclosure Statement of Financial Interest
I, Ji-Yeon Hong, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation. ㅁ

3. 40/M C/C Severe retrosternal chest pain (onset 1hrs) Mode
about 20 min after taking 100 mg Kamagra®
(sildenafil citrate from India) before sexual intercourse.
approximately 1400 ml alcohol 3 hours before receiving sildenafil.
HTN/DM/dyslipidemia (-/-/-)
Familial Hx (-)
Heavy smoker (+) 50PYS
Previous exertional chest pain / DOE (-/-)
BP 70/40mmHg 80bpm

4. CXR in ER

5. 1st ECG in ER CK-MB <1.0ng/ml, Troponin I <0.01ng/ml
STEMI inferioir wall  massive hydration d/t shock and prepare primary PCI

6. 2nd ECG in ER 30min after hydration (N/S 1L)  subsided chest pain
1. Breaking dawn 2. Heavy drinking 3. ECG change 4. subsided chest pain
?? Variant angina

7. EchoCG

8. CAG

9. PCI in RCA and LCx
Endeavor onyx 2.75X 23mm
Endeavor onyx 3.0X 23mm

10. Sildenafil citrate Oral phosphodiesterase type 5 (PDE5) inhibitor
1st oral drug for the treatment of erectile dysfunction by FDA & European Medicines Evaluation Agency.
no direct effect on relaxation of isolated human corpus cavernosum
increases the effect of NO on thrombocytes and vascular smooth muscle cells by inhibiting PDE5 receptor responsible for degradation of cyclic guanosine monophosphate (cGMP) in the corpus cavernosum 

11. Sildenafil contraindication
Severe hepatic impairment (decreased liver function)
Severe impairment in renal function
Hypotension (low blood pressure)
Recent stroke and heart attack
Hereditary degenerative retinal disorders (including genetic disorders of retinal phosphodiesterase)
Also, the use of CYP3A4 or P450 inhibitor (which are the cytochromes responsible for Viagra metabolism), greatly increases the risk of negative side effects..
Because sildenafil is a vasodilator (although mainly locally) in needs to be used cautiously because it lowers blood pressure
Viagra should not be given to patients who are taking nitrate, because nitrate are also a strong vasodilator. The use of both could cause major heart problems.

12. Causes of dropping blood pressure?
“He did not take nitrate!!”
Heavy drinking?
Coronary steel effect?
Sildenafil overdose?

13. Take home message
Doctors should pay attention to prescriptions for sildenafil, especially in patients with high risk of coronary artery disease.