Sildenafil Positivity and Chronic Cardiac Pathology in Men Who Died of Ischemic Heart Disease: An Age- and Sex-Matched Postmortem Case–Control Study

Background: Erectile dysfunction and cardiovascular disease share common pathophysiological mechanisms, yet little is known about the postmortem cardiac profile of men with detectable sildenafil use. This study investigated whether postmortem sildenafil positivity is associated with acute or chronic cardiac pathological findings in men who died of ischemic heart disease. Methods: In a sample of 154 male decedents who died of ischemic heart disease, postmortem cardiac and toxicological findings in 77 sildenafil-positive cases were compared with those of age-matched controls. Heart weight z-scores were calculated based on 27,645 reference autopsies. Multivariable logistic regression analyses were performed to identify independent associations. Results: No significant differences were observed between groups regarding acute ischemic pathologies. However, chronic cardiac findings were more prevalent in the sildenafil-positive group, including coronary artery disease (96.1% vs. 85.7%; p = 0.025), congestive heart failure (40.3% vs. 24.7%; p = 0.039), prior coronary artery bypass grafting (24.7% vs. 11.7%; p = 0.037), increased heart weight (547.7 gr vs. 507.5 gr; p = 0.037) and z-score (+1.63 vs. 1.08; p = 0.040), and coronary calcification (88.3% vs. 74.0%; p = 0.023). After adjustment for cardiovascular comorbidities, only coronary calcification remained independently associated (adjusted OR: 2.586; 95% CI: 1.076–6.215; p = 0.034). Conclusions: Sildenafil-positive cases showed no excess of acute ischemic pathology. However, sildenafil-positive cases had a greater burden of chronic cardiac pathology, particularly coronary calcification. These findings are consistent with the proposed role of coronary artery calcification as a surrogate marker of erectile dysfunction and cardiovascular disease. They also underscore the importance of cardiovascular risk assessment in sildenafil users and support a cautious approach in individuals with poor cardiac reserve.