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Angina - stable - Management
What should I advise about sexual activity?

  • Reassure the person that, if they can briskly climb up and down two flights of stairs without any angina symptoms, sexual activity is unlikely to precipitate an episode of angina.
  • If sexual activity does precipitate an episode of angina, sublingual glyceryl trinitrate (GTN) taken immediately before intercourse may help prevent subsequent attacks.
  • The concomitant use of nitrates or nicorandil with phosphodiesterase inhibitors (sildenafil, tadalafil, and vardenafil), often used in the treatment of erectile dysfunction, is contraindicated.
  • Advise people with angina who take a phosphodiesterase inhibitor that:
    • They should not use glyceryl trinitrate (GTN) for at least 24 hours before taking sildenafil or vardenafil and for at least 48 hours before taking tadalafil.
    • They should not use GTN for at least 24 hours after taking sildenafil or vardenafil and for at least 48 hours after taking tadalafil.
    • If they have an episode of angina during sexual intercourse, they must not use GTN. They should stop sexual activity and, if their pain does not resolve, they should call for an ambulance.
Basis for recommendation

The information on angina and sexual activity is in line with that from the British Heart Foundation and guidelines from the European Society of Cardiology [BHF, 2006; Fox et al, 2006a].

Interaction between nitrates/nicorandil and phosphodiesterase inhibitors

  • The combination of a phosphodiesterase inhibitor and a nitrate (including amyl nitrite) or nicorandil can result in excessive hypotension and possibly precipitate myocardial infarction [Baxter, 2008].
    • The interaction with phosphodiesterase inhibitors is well established and clinically significant.
    • It is not yet established whether nicorandil interacts with phosphodiesterase inhibitors to the same extent, but the manufacturers recommend that its use is contraindicated with all phosphodiesterase inhibitors.
    • The duration between taking a nitrate or nicorandil and a phosphodiesterase inhibitor is based on expert consensus and information from the manufacturers of sildenafil, tadalafil, and vardenafil.

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