Common Questions · Erectile dysfunction · No. 33
Are these pills safe for my heart?
A specific, answerable fear that usually goes unanswered. Sex with a familiar partner costs about the same effort as walking a mile on the flat.
By Mr Musaab Yassin, Consultant Urological Surgeon & Andrologist. Oxford and central London.
For most appropriately assessed men, PDE5 inhibitors such as sildenafil and tadalafil have a well-established cardiovascular safety record. In fact, large observational analyses have found PDE5-inhibitor use associated with lower rates of major cardiovascular events and all-cause mortality—although those associations do not prove the drugs themselves prevent heart attacks.1
The major safety issue is different and very specific: PDE5 inhibitors and nitrate medicines must not be combined casually because the combination can produce dangerous hypotension.2
Why do ED and heart disease appear together?
Penile arteries are small and erectile function depends on healthy endothelium. Diabetes, smoking, hypertension and dyslipidaemia can therefore affect erections and coronary circulation through shared vascular pathways. ED may precede overt cardiovascular disease in some men.
Are sildenafil and tadalafil bad for the heart?
In men whose cardiovascular condition is stable enough for sexual activity, the medicines are generally well tolerated. A 2024 systematic review/meta-analysis of 16 observational studies covering more than 1.25 million people found PDE5i use associated with lower MACE (RR 0.78) and mortality (RR 0.70).1 Because this is observational, healthier-user effects and other confounding cannot be excluded.
What is the nitrate interaction?
Nitrates such as glyceryl trinitrate (GTN) and isosorbide preparations increase nitric-oxide signalling. PDE5 inhibitors amplify the same downstream pathway. Together they can cause haemodynamically significant blood-pressure reduction. Reviews therefore maintain the contraindication and advise avoiding acute nitrate therapy after recent PDE5 inhibitor exposure.2
What if I have angina or previous heart disease?
Do not self-exclude and do not self-prescribe. The useful questions are whether your cardiovascular disease is stable, what exercise you can comfortably perform, whether you use nitrates and whether other medicines interact. Sometimes cardiology review is appropriate before resuming sexual activity or ED treatment.
Can ED itself be a reason to check my cardiovascular risk?
Yes—particularly when ED is persistent, unexplained or appears earlier than expected. Blood pressure, lipids, glucose/HbA1c, smoking and weight are often more important to long-term health than the erectile prescription itself.
How much effort is sex, in practice?
The Princeton consensus puts a figure on it that men find more useful than any reassurance: sexual activity with a familiar partner costs about two to three METs — roughly the effort of walking a mile on the flat in twenty minutes, or briskly climbing two flights of stairs.
If you can do that without chest pain or undue breathlessness, your cardiovascular risk during sex is low. The consensus also makes a point that gets missed: many men remain on nitrate prescriptions they no longer need, and that is worth reviewing with whoever prescribes them rather than simply accepting the contraindication for life.
Bottom line
PDE5 inhibitors are not generally “dangerous heart drugs”; in suitable patients they are well studied. The critical exception is nitrate therapy and certain unstable cardiovascular situations. ED should also be used as an opportunity to assess vascular health rather than simply issue a repeat prescription.
The one absolute bar is nitrates, and a surprising number of men are still on a nitrate prescription they no longer need — which is worth reviewing rather than accepting. Otherwise, if you can climb two flights of stairs briskly without chest pain, you can almost certainly have sex and take these tablets safely.
If this sounds like you
A first consultation is £295, and follow-up £190. It usually runs at least twenty minutes; allow up to an hour if you are likely to need a scan, a flow test, or blood or urine tests on the day. You do not need a referral to book privately, and you are under no obligation to proceed with anything.
Send an enquiry · Symptom questionnaire · Compare the treatments, with the evidence
The 2 studies behind this page▾
- Long-term effects of phosphodiesterase-5 inhibitors on cardiovascular outcomes and death: a systematic review and meta-analysis — Soulaidopoulos S, Terentes-Printzios D, Ioakeimidis N, et al.. European Heart Journal: Cardiovascular Pharmacotherapy. 2024. doi:10.1093/ehjcvp/pvae029
- Phosphodiesterase Type 5 Inhibitors and Oral Nitrates in Male Patients with Ischemic Heart Disease — Morrisette MJ, Dunn S. Current Cardiology Reports. 2023. doi:10.1007/s11886-023-01873-y
Mr Musaab Yassin is a Consultant Urological Surgeon and Andrologist practising in Oxford and central London. FRCS (Urol). GMC 6118378. Reviewed August 2026.
This page gives general information and does not replace an individual assessment. Figures quoted come from published research and describe groups of patients rather than any one person — your own history, anatomy and priorities change what they mean for you.