The irony is that older men, and men with cardiac disease, are more likely to be impotent and, therefore, ask for Viagra. But those are the men who are most susceptible to Viagra-related complications.

"We're taking men who perhaps should not be having sex and allowing them to have sex by benefit of Viagra without actually addressing what are the needs of the heart first," said Dr. Gregory Broderick of the Mayo Clinic in Jacksonville, Florida.

"Traditionally, we would tell the patient (that) if you can climb a flight of stairs at a brisk pace, then you shouldn't be having problems with chest pain during sex," Broderick said. "I think that that's a totally naive and really inappropriate statement."

To give physicians more guidance, the American Heart Association and the American College of Cardiology have issued the first formal recommendations for the safe and effective use of Viagra.

They recommend doctors consider giving a treadmill test before prescribing Viagra if a patient has heart disease or is at high risk for developing it. The test determines whether the patient's heart can handle a certain rate of exercise.

The guidelines also advise doctors that Viagra could be dangerous for men who are taking more than one medication for high blood pressure. And they repeat previous warnings that men taking nitrate drugs, including nitroglycerin, should not use Viagra because mixing the drug with nitrates can cause a dangerous drop in blood pressure.

The new guidelines make it clear that while Viagra is indeed safe for many men with heart disease, it takes close attention from doctors to figure out who is at risk for complications and who is not.

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