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• W3146562499 abstract "J Feenstra and colleagues1Feenstra J , van Drie-Pierik RJHM, Laclé CF, Stricker BHCh. Acute myocardial infarction associated with sildenafil.Lancet. 1998; 352: 957-958Summary Full Text Full Text PDF PubMed Scopus (103) Google Scholar report a patient who developed an acute myocardial infarction after taking one 50 mg sildenafil tablet. Erectile dysfunction is common in end-stage renal disease (ESRD) and treatment of this symptom has been limited. Since cardiovascular diseases are common in ESRD, an increased prevalence of sildenafil side-effects can be expected in this population. We report a patient with chronic renal failure who presented with acute thrombosis of radial arteriovenous fistula after sildenafil consumption. A 54-year-old black man was seen at our clinic 3 days after occlusion of a left forearm arteriovenous fistula (AVF). He had been followed for 4 years for chronic renal failure related to a biopsy-proven chronic tubulo-interstitial nephropathy without evidence of immunological infectious or toxic aetiology. Left-ventricular hypertrophy was also present, associated with hypertension requiring a triple-drug regimen. He had no history of smoking, diabetes mellitus, or hypercholesterolaemia. Despite good control of hypertension, renal insufficiency progressed and creatinine clearance reached 12 mL per min in September, 1998, leading to the development of an AVF. Echocardiography showed normal left-ventricular function and estimated cardiac index was 3·1 L min-2 m-2. The vessels appeared healthy and a direct vascular anastomosis between left radial vein and artery was done. The patient was taught how to listen for AVF murmur and thrill. 3 weeks after surgery, AVF was well developed and judged functional. Because of intermittent erectile dysfunction associated with anti-hypertensive therapy (losartan 50 mg, amlodipine 10 mg, and furosemide 80 mg daily), sildenafil was prescribed by his general practitioner. Two 25 mg tablets were first used without improvement of sexual function, but the patient achieved brief sexual intercourse 1 h after taking a 50 mg tablet. 30 min after coitus, the patient had transient isolated forearm pain and could no longer feel the thrill from the fistula. At this time, he was free of chest pain, headache, nausea, and visual disturbances. Physical examination 3 days later was normal apart from complete AVF occlusion. Blood pressure was 124/88 mm Hg. Serum creatinine was stable (560 μmol/L), plasma ionogram was normal, haemoglobin was 119 g/L without erythropoietin use. The electrocardiogram remained unchanged. The close temporal relation between sildenafil ingestion and AVF occlusion suggests that this drug was related to the acute vascular event. However, since this accident occurred after short sexual intercourse, sexual exertion cannot be excluded as a precipitating factor. Information from the manufacturers suggests an accumulation of sildenafil in patients with mild to moderate renal failure, but there are no data for patients with severe renal failure or those on dialysis. Sildenafil acts at the corpora cavernosa level by inhibiting the breakdown of cyclic guanosine monophosphate (GMP) by a specific cyclic-GMP phosphodiesterase.2Goldstein I Lue TF Padman-Nathan H Rosen RC Steers WD Wicker PA Oral sildenafil in the treatment of erectile dysfunction.N Engl J Med. 1998; 338: 1397-1404Crossref PubMed Scopus (2028) Google Scholar However, cyclic-GMP is also implicated in signalling pathways, including those for endogenous systemic vasodilators such as nitric oxide or atrial natriuretic peptide, two substances that are usually raised in patients with chronic renal failure.3Rysz J Luciak M Kedziora J Blaszczyk J Sibinska E Nitric oxide release in the peripheral blood during hemodialysis.Kidney Int. 1997; 51: 294-300Crossref PubMed Scopus (39) Google Scholar, 4De Nicola L Bellizzi V Cianciaruso B et al.Pathophysiological role and diuretic efficacy of atrial natriuretic peptide in renal patients.J Am Soc Nephrol. 1997; 8: 445-455PubMed Google Scholar Sildenafil has moderate vasodilator properties.2Goldstein I Lue TF Padman-Nathan H Rosen RC Steers WD Wicker PA Oral sildenafil in the treatment of erectile dysfunction.N Engl J Med. 1998; 338: 1397-1404Crossref PubMed Scopus (2028) Google Scholar Accumulation of the drug by reduced renal clearance could have enhanced this effect, increasing systemic vasodilation associated with antihypertensive treatment, and reducing blood flow in the vascular access leading to thrombosis. Our case, and the frequency of the underyling cardiovascular disease in a patient with chronic renal failure, suggest cautious use of sildenafil in ESRD patients." @default.
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• W3146562499 date "1998-12-01" @default.
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• W3146562499 title "Acute myocardial infarction associated with sildenafil" @default.
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