Should erectile dysfunction be considered as a marker for acute myocardial infarction? Results from a retrospective cohort study

Cardiovascular and metabolic syndrome risk among men with and without erectile dysfunction: case-control study

CONTEXT AND OBJECTIVE

Erectile dysfunction has been associated with cardiovascular diseases. The aim here was to evaluate cardiovascular risk through the Framingham Risk Score (FRS) criteria, C-reactive protein (CRP) assays and presence of metabolic syndrome (MS) in men with and without erectile dysfunction diagnosed within a healthcare program.

DESIGN AND SETTING

A retrospective case-control study was conducted. The patients were selected from a healthcare program at the Hospital Israelita Albert Einstein, between January and December 2007.

METHODS

222 men were retrospectively selected, and they were divided into two groups: men with erectile dysfunction (n = 111) and men without erectile dysfunction (n = 111). The patients were stratified according to the International Index of Erectile Function-Erectile Function domain (IIEF-EF domain). CRP and FRS were analyzed and the two groups were compared.

RESULTS

The CRP levels were significantly higher among men with erectile dysfunction (P = 0.04). Patients with erectile dysfunction also had high FRS (P = 0.0015). CRP and FRS did not correlate with the severity of erectile dysfunction. The presence of metabolic syndrome was greater among men with erectile dysfunction (P < 0.05). The severity of erectile dysfunction was directly associated with metabolic syndrome.

CONCLUSION

Men with erectile dysfunction presented higher cardiovascular risk according to the FRS criteria and CRP measurements. Severe erectile dysfunction seemed to have a correlation with metabolic syndrome.

Asymmetrical dimethylarginine and severity of erectile dysfunction and their impact on cardiovascular events in patients with acute coronary syndrome

INTRODUCTION

Coronary artery disease (CAD) and vascular erectile dysfunction (ED) are related to endothelial dysfunction. Elevated asymmetrical dimethylarginine (ADMA) levels and ED are common in patients with increased cardiovascular risk. Our aim was to investigate whether ADMA has a predictive role for major adverse cardiovascular events (MACE) in acute coronary syndrome (ACS). The secondary aim of this study was to investigate whether severity of ED predicts MACE in these patients.

MATERIAL AND METHODS

Follow-up data were available for severity of ED in 71 patients with ACS. Plasma ADMA levels were determined by ELISA in 57 patients. Erectile dysfunction was assessed by the International Index of Erectile Function-6 (IIEF-6) score. Major adverse cardiovascular events (reinfarction, all-cause hospitalisation, stroke and all-cause death) was evaluated after a median of 10 months.

RESULTS

Severe ED had no significantly increased hazard ratio for cardiovascular events compared with mild, mild to moderate, and moderate ED (0.259 [95% CI 0.041-1.6], p = 0.147; 0.605 [95% CI 0.095-3.8], p = 0.594; 0.980 [95% CI 0.233-4.1], p = 0.978; and 0.473 [95% CI 0.052-1.3], p = 0.508). The patients who had ADMA levels ≥ 0.32 µmol/l had no significantly increased hazard ratio for cardiovascular events compared with patients who had ADMA levels < 0.32 µmol/l (2.018 [95% CI 0.615-6.6], p = 0.247).

CONCLUSIONS

Severity of ED and ADMA did not increase the risk of cardiovascular events in follow-up patients with ACS in our study. Larger prospective studies are necessary to evaluate whether ADMA predicts cardiovascular events in patients with ACS.

Subtypes of depression among patients with Alzheimer's disease and other dementias

OBJECTIVES

We compared the prevalence of subtypes of depression in patients with Alzheimer's disease (AD), vascular dementia (VaD), and unspecified dementia (UD).

METHODS

Using the Integrated Healthcare Information Services database, we conducted an analysis of subtypes of depression (major depressive disorder, depressive disorder not otherwise specified, dysthymic disorder; depressive psychosis, and adjustment disorder depressive) among patients with AD, VaD, and UD. Six thousand four hundred and forty patients aged 60 years or older with dementia (2947 with AD, 725 with VaD, and 2768 with UD) were identified from January 1 to December 31, 2001. Both subtypes of depression and dementia subgroups were diagnosed using criteria from the International Classification of Diseases, 9th version.

RESULTS

The overall prevalence of depressive disorders was 27.41%. The prevalence of depressive disorders was significantly higher in VaD (44.14%) and UD (32.48%) patients compared with AD (18.53%, P < .0001) patients. The AD patients had the lowest prevalence of all subtypes of depression. The VaD patients, compared with both AD and UD (P < .005), had a significantly higher prevalence of: 1) depressive disorder not otherwise specified, 2) major depressive disorder, and 3) dysthymic disorder. Adjustment disorder with depressive symptoms was more common in the UD subgroup, whereas the rate of depressive psychosis was similar in all dementia subgroups

CONCLUSIONS

This study supports the view that depressive disorders are more prevalent in VaD compared with UD and AD, and provides indicators to the clinician for further evaluation of depression in dementia subgroups.

Independent determinants of coronary artery disease in erectile dysfunction patients

INTRODUCTION

There is growing evidence of a link between erectile dysfunction (ED) and coronary artery disease (CAD).

AIMS

The purpose of this study was to explore the independent determinants of CAD in ED outpatients.

METHODS

This study enrolled 243 patients, ranging in age from 21 to 81 years old, suffering from ED as diagnosed by the International Index of Erectile Function (IIEF) scores. All patients underwent exercise stress tests or thallium-201 single-photon emission computed tomography perfusion imagings. Based on examination results, patients were divided into study (22 patients with a positive finding) and control groups (221 patients with a negative finding).

MAIN OUTCOME MEASURES

The differences of demographic characteristics, biochemical profiles, pro-inflammatory and inflammatory markers, and echocardiographic characteristics between study and control group were compared.

RESULTS

The age, presence of DM and current smoking status were significant high in the study group. A significant lower high-density lipoprotein (HDL) cholesterol level, a higher percentage of HDL cholesterol level < 40 mg/dL, and a higher apo-lipoprotein B/A1, high sensitive C-reactive protein (hs-CRP) and homocysteine found in the study group. The Framingham cardiac risk scores, the ratio of mitral inflow velocity to early diastolic velocity in the annulus derived by tissue Doppler imaging (E/Et), the ratio of E/Et > or = 15, the value of carotid intima-media thickness (IMT), and IMT > or = 1 mm were higher in study group than in the control group. In stepwise multiple logistic regression analysis, a high waist-to-hip ratio (WHR), high IMT, high E/Et, hs-CRP levels, LDL cholesterol > or = 130 mg/dL, smoking status, and the presence of DM and metabolic syndrome (MS) were independent determinants of CAD in ED patients.

CONCLUSIONS

This study first shows the independent determinants of CAD in ED outpatients. This novel finding may improve the screening of low-risk ED patients for CAD.

Erectile dysfunction and risk of clinical cardiovascular events: a meta-analysis of seven cohort studies

INTRODUCTION

For many years, erectile dysfunction (ED) has been considered as a complication of cardiovascular disease (CVD) or regarded as a late consequence of generalized arterial disease. However, a growing body of evidence suggests that ED is an early manifestation of atherosclerosis and a precursor to systemic vascular disease.

AIM

We conducted a meta-analysis to evaluate the association between ED and the risk of CVD events.

METHODS

Relevant studies published between January 1966 and September 2009 were identified by searching Medline, Embase, and The Cochrane Library. Studies were selected using a prior defined criteria. The strength of the relationship between ED and CVD events was assessed by adjusted relative risks (RRs).

MAIN OUTCOME MEASURES

The adjusted RRs of CVD events.

RESULTS

A total of 45,558 participants from seven cohort studies (eight full-text articles) were identified in this meta-analysis. The studies provided adjusted RRs estimates for ED subjects comparing with health subjects, leading to a pooled adjusted RR of 1.47 (95% confidence interval [CI], 1.29-1.66, P < 0.001; P for heterogeneity = 0.152; I(2)  = 36.2%) for CVD events. The risks of CVD, all-cause mortality and myocardial infarction were 1.41 (95% CI, 1.22-1.64 P < 0.001), 1.23 (95% CI, 1.02-1.48; P = 0.034), and 1.43 (95% CI, 1.10-1.85 P = 0.007), respectively. The overall adjusted RR decreased significant from 1.63 (<7 years) to 1.37 (≥ 7 years) along with the elongation of follow-up.

CONCLUSIONS

There is evidence of an increased risk of CVD events for patients with ED. Patients who are discovered to have ED are supposed to be thoroughly assessed for cardiovascular risk and occult systemic vascular disease.

Longitudinal study on pediatric dyslipidemia in population-based claims database

PURPOSE

To examine the rate of lipid testing among children from a large US medical insurance claims database, describe the characteristics of pediatric dyslipidemia, and assess the sensitivity of the International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes for identifying dyslipidemic children.

METHODS

This retrospective cohort study used the claims data from the Integrated Healthcare Information Services (IHCIS), for the years 2003-2006. Two study cohorts consisted of children with laboratory-defined and diagnosis/treatment-defined dyslipidemia, respectively. They were compared to age- and gender-matched children without dyslipidemia, with respect to co-morbidities during the 6-month prior to and 12-month after the first dyslipidemic laboratory value or diagnosis/treatment.

RESULTS

Seven per cent of the children who had laboratory values available in the database had a cholesterol test during the study period. Only 15% of laboratory-defined children (n = 23,475) had a dyslipidemia diagnosis. Cholesterol-modifying medications were rarely prescribed. Substantially more laboratory-defined children than their comparators were obese (8 times), had diabetes mellitus (10 times), or had hypertension (5 times). These co-morbidities were even higher among diagnosis/treatment-defined children.

CONCLUSIONS

The rate of lipid testing among children was low. The ICD-9-CM diagnostic codes showed low sensitivity against laboratory definitions. Though only a small proportion of dyslipidemic children were diagnosed or treated with a medication, co-morbidities associated with dyslipidemia were common.

Incidence and economic burden of suspected adverse events and adverse event monitoring during AF therapy

OBJECTIVE

Rhythm- and rate-control therapies are an essential part of atrial fibrillation (AF) management; however, the use of existing agents is often limited by the occurrence of adverse events. The aim of this study was to evaluate suspected adverse events and adverse event monitoring, and associated medical costs, in patients receiving AF rhythm-control and/or rate-control therapy.

RESEARCH DESIGN AND METHODS

This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from 2002-2006. Patients hospitalized for AF (primary diagnosis), and who had at least 365 days' enrollment before and after the initial (index) AF hospitalization, were included in the analysis. Suspected AF therapy-related adverse events and function tests for adverse event monitoring were identified according to pre-specified diagnosis codes/procedures, and examined over the 12 months following discharge from the index hospitalization. Events/function tests had to have occurred within 90 days of a claim for AF therapy to be considered a suspected adverse event/adverse event monitoring.

RESULTS

Of 4174 AF patients meeting the study criteria, 3323 received AF drugs; 428 received rhythm-control only (12.9%), 2130 rate-control only (64.1%), and 765 combined rhythm/rate-control therapy (23.0%). Overall, 50.1% of treated patients had a suspected adverse event and/or function test for adverse event monitoring (45.5% with rate-control, 53.5% with rhythm-control, and 61.2% with combined rhythm/rate-control). Suspected cardiovascular adverse events were the most common events (occurring in 36.1% of patients), followed by pulmonary (6.1%), and endocrine events (5.9%). Overall, suspected adverse events/function tests were associated with mean annual per-patient costs of $3089 ($1750 with rhythm-control, $2041 with rate control, and $6755 with combined rhythm/rate-control).

LIMITATIONS

As a retrospective analysis, the study is subject to potential selection bias, while its reliance on diagnostic codes for identification of AF and suspected adverse events is a source of potential investigator error. A direct cause-effect relationship between suspected adverse events/function tests and AF therapy cannot be confirmed based on the claims data available.

CONCLUSIONS

The incidence of suspected adverse events and adverse event monitoring during AF rhythm-control and/or rate-control therapy is high. Costs associated with adverse events and adverse event monitoring are likely to add considerably to the overall burden of AF management.

Cardiovascular disease risk, vascular health and erectile dysfunction among middle-aged, clinically depressed men

Erectile dysfunction (ED) is especially common in men with major depressive disorder (MDD). This study examined the extent to which risk factors for cardiovascular disease (CVD) and vascular endothelial dysfunction were associated with ED severity in MDD patients. The sample included 46 middle-aged [M (s.d.)=53 (7) years], sedentary men diagnosed with MDD. ED severity was assessed by the Arizona Sexual Experiences Scale (ASEX), item 3. Depression severity was measured by the Beck Depression Inventory-II (BDI). The Framingham risk score was calculated as a composite measure of CVD risk factors. Vascular endothelial function was measured by flow-mediated dilation (FMD) of the brachial artery. Regression analysis showed that ASEX scores were predicted by the greater Framingham risk score (beta=0.41, P=0.008) and lower FMD (beta=-0.38, P=0.01), but not by BDI scores (beta=0.00, P=0.99). When FMD was included in the regression model, the relationship between Framingham risk and ASEX scores was partially attenuated (beta=0.27, P=0.08). ED was associated with greater CVD risk and impaired vascular endothelial function in depressed men. CVD risk factors may affect ED through impairment of vascular endothelial function.

How to save a life during a clinic visit for erectile dysfunction by modifying cardiovascular risk factors

Erectile dysfunction (ED) is an early marker for systemic atherosclerosis and is a predictor for coronary artery disease and cardiac events. The aim of this paper is to convey the importance of addressing cardiovascular risk factors in patients with ED and to inform urologists as well as other physicians who are not specialized in cardiology how to carry out a basic cardiovascular evaluation, including history, physical examination and objective data. We review the evidence and pathophysiology linking ED to cardiovascular disease, and then describe how to carry out a basic cardiovascular evaluation. We present data from the literature showing that appropriate use of lifestyle modifications and medical therapy has a positive effect on mortality, on numerous cardiovascular end points and on ED. Suggestions of when to refer the ED patient to an internist or cardiologist are provided. Identifying and treating cardiovascular risk factors may not only benefit the patient's ED, but it might also save the patient's life.

National assessment of Medicare prescription plan coverage gaps among patients with atrial fibrillation in the US

INTRODUCTION

The Medicare Part D prescription plan has a coverage gap from $2250 to $5100 per year (2006 thresholds) in which patients pay full drug costs (the "donut hole"). We examined prescription costs in patients aged >or=65 years with atrial fibrillation (AF), and the proportions entering/exiting the donut hole in 2006.

METHODS

This retrospective cohort study used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database from January 2005 to December 2006. Medicare Advantage patients aged >or=65 years who were hospitalized with a primary/secondary discharge diagnosis of AF, or had >or=2 outpatient AF claims without hospitalization in 2005, were identified. Total 2006 prescription costs were calculated by summing health plan payments and patient copayments.

RESULTS

Of 16,655 patients included in the analysis, 1527 were hospitalized with a primary AF diagnosis, 6067 with a secondary AF diagnosis, and 9061 had outpatient-managed AF in 2005. Mean 2006 per-patient prescription costs were $3457.16. In total, 58.8% of patients reached the $2250 threshold in a mean of 199 days; including 59.9% of primary AF hospitalization, 63.5% of secondary AF hospitalization, and 55.5% of patients with outpatient-managed AF. Of the overall population, 21.2% reached the $5100 threshold in a mean of 257 days; including 21.3% of primary AF hospitalization, 27.3% of secondary AF hospitalization, and 17.2% of patients with outpatient-managed AF. AF-related drugs accounted for only 15% of the total prescription costs, with the majority of costs relating to the treatment of non-AF comorbidities.

CONCLUSIONS

In 2006, total annual prescription costs in this population of Medicare Advantage AF patients were considerable. In this sample population, over half of patients would have had prescription costs in excess of the 2006 Part D donut hole threshold. The costs of AF treatment itself were relatively low, with the majority of prescription costs relating to the treatment of non-AF comorbidities.

The association between erectile dysfunction and cardiovascular risk in men with Type 2 diabetes in primary care: it is a matter of age

AIMS

Erectile dysfunction (ED) prevalence is usually based on questionnaires, too elaborate for daily practice. The single question for ED prevalence is unknown. Literature reports an independent association between ED and both cardiovascular disease (CVD) and diabetes. Whether routinely asking men with Type 2 diabetes (DM2) about ED identifies those at elevated risk for CVD is unknown. We assessed cardiovascular risk of DM2 men with ED.

DESIGN AND METHODS

This was a cross-sectional study in primary care. During annual check-up, the practice nurse asked 1823 DM2 men: "Do you have erection problems? Yes/no." ED prevalence rate was calculated. Age, medication, and other known factors associated with ED and/or CVD were used in univariate analysis (odds ratio [OR], Student's t test, and Mann-Whitney test). This revealed confounding variables used in the multivariable analysis. The association between ED and history of cardiovascular disease (HCVD) was assessed by logistic regression analysis. In patients with no HCVD, we assessed the association between ED and 10-year United Kingdom Prospective Diabetes Study (UKPDS) coronary heart disease risk by linear regression analysis.

RESULTS

The prevalence of ED in DM2 patients was 41.3%. There was no independent association between ED and HCVD [adjusted OR, 1.2 (95% CI, 0.9-1.5)]. The 10-year UKPDS CHD risk difference between men with and without ED was 5.9% (95% CI, 3.2-8.7), but after adjustment for age, this association disappeared [adjusted risk difference, 0.6% (95% CI, -1.5 to 2.7)].

CONCLUSION

The ED prevalence rate assessed by a single question was comparable to that assessed by questionnaires. ED neither did independently relate to patients' cardiovascular history nor to cardiovascular risk.

Incidence and temporal pattern of hospital readmissions for patients with atrial fibrillation

BACKGROUND

Atrial fibrillation (AF) is prevalent and has a high cost burden. Among the main drivers of cost is inpatient care; however, little is known about patterns of hospital readmissions for AF.

OBJECTIVE

To evaluate the incidence and temporal pattern of readmission in AF patients.

METHODS

This retrospective, cohort analysis used claims data from the Integrated Healthcare Information Systems National Managed Care Benchmark Database for 2002-2006. Patients hospitalized for AF (primary discharge diagnosis) were identified. Data on the first readmission for AF over 1 year following an index hospitalization were analyzed for chronic AF (any AF-related claims in 1 year before index hospitalization) and newly-diagnosed AF patients (no prior AF-related claims).

RESULTS

Overall, 4174 patients hospitalized with primary AF were identified; 1637 had chronic AF and 2537 newly-diagnosed AF. Mean age of chronic AF patients was 62.4 years and 61.2% were male; for newly-diagnosed AF, mean age was 61.4 years and 57.8% were male. In the year following index hospitalization, 12.5% of chronic AF patients were readmitted for AF, with a mean time to readmission of 142.5 days (median 108 days). Among newly-diagnosed AF patients, 10.1% were readmitted for AF, with a mean time to readmission of 133.8 days (median 112 days). For chronic AF, 17.6%, 43.4%, and 65.8% of readmissions occurred within 1, 3, and 6 months, respectively, versus 22.7%, 44.5%, and 67.2%, respectively, for newly-diagnosed AF.

LIMITATIONS

Limited data were available on patients' clinical profile, treatment patterns, or the reasons for hospitalization/readmission. The term chronic AF only captured patients with a history of AF and data were not available to classify patients according to the presence of paroxysmal, permanent, or persistent AF.

CONCLUSIONS

Patients with newly-diagnosed or chronic AF are often readmitted in the year following hospitalization with most readmissions occurring within 6 months of the index hospitalization.

Erectile dysfunction and cardiovascular disease: efficacy and safety of phosphodiesterase type 5 inhibitors in men with both conditions

Risk factors for cardiovascular disease and erectile dysfunction (ED) are similar, as might be expected given their shared etiologic and pathophysiologic origins. It is now generally accepted that most cases of ED result from a vascular disturbance of the endothelium. Recent epidemiological studies have documented a strong association between ED and comorbid conditions such as hypertension, diabetes mellitus, and dyslipidemia. Phosphodiesterase type 5 (PDE5) inhibitors are recommended as first-line therapy for erection problems of all etiologies and severities. The efficacy and safety of PDE5 inhibitors in the general ED population is well documented and has been extensively reviewed. To examine the association between ED and vascular disorders in the context of current knowledge regarding PDE5 inhibitors, an electronic search was performed of articles published from January 2002 through April 2008 using the PubMed, EMBASE, and MEDLINE databases. Although preference was given to randomized, blinded, controlled clinical trials, data from retrospective studies were also reviewed when appropriate. This analysis revealed that the clinical evidence linking ED to future cardiovascular events is compelling, presenting physicians with a unique interventional opportunity to address underlying cardiovascular health concerns in men presenting with ED. In most studies, PDE5 inhibitors were shown to effectively and safely improve erectile function regardless of cause, severity, or presence of comorbid conditions, including hypertension, diabetes mellitus, and dyslipidemia.

Erectile dysfunction and cardiovascular disease: efficacy and safety of phosphodiesterase type 5 inhibitors in men with both conditions

Risk factors for cardiovascular disease and erectile dysfunction (ED) are similar, as might be expected given their shared etiologic and pathophysiologic origins. It is now generally accepted that most cases of ED result from a vascular disturbance of the endothelium. Recent epidemiological studies have documented a strong association between ED and comorbid conditions such as hypertension, diabetes mellitus, and dyslipidemia. Phosphodiesterase type 5 (PDE5) inhibitors are recommended as first-line therapy for erection problems of all etiologies and severities. The efficacy and safety of PDE5 inhibitors in the general ED population is well documented and has been extensively reviewed. To examine the association between ED and vascular disorders in the context of current knowledge regarding PDE5 inhibitors, an electronic search was performed of articles published from January 2002 through April 2008 using the PubMed, EMBASE, and MEDLINE databases. Although preference was given to randomized, blinded, controlled clinical trials, data from retrospective studies were also reviewed when appropriate. This analysis revealed that the clinical evidence linking ED to future cardiovascular events is compelling, presenting physicians with a unique interventional opportunity to address underlying cardiovascular health concerns in men presenting with ED. In most studies, PDE5 inhibitors were shown to effectively and safely improve erectile function regardless of cause, severity, or presence of comorbid conditions, including hypertension, diabetes mellitus, and dyslipidemia.

Does regular consumption of green tea influence expression of vascular endothelial growth factor and its receptor in aged rat erectile tissue? Possible implications for vasculogenic erectile dysfunction progression

Erectile dysfunction (ED) is a highly prevalent disease affecting millions of men worldwide with a tendency for widespread increase. ED is now considered an early manifestation of atherosclerosis and, consequently, a precursor of systemic vascular disease. Atherosclerosis and ED share potentially modifiable risk factors, as smoking or high-fat food intake, but it is unclear how regular consumption of anti-oxidant rich drinks, which exhibit recognised anti-atherosclerotic features, affects ED progression. The objective of this study was to evaluate the modulating effects of chronic consumption of catechin-rich beverages on the vascular structure of the rat corpus cavernosum, and how this could contribute to delay or prevention of the onset of ED. Male Wistar rats aged 12 months were treated with green tea (GT) or a green tea extract solution (GTE) as the only liquid source for 6 months. Consumption of GT and GTE led to decreased plasma androgen levels without any significant change in plasma lipid levels. A reduction in corpus cavernosum intracellular storage of lipids, associated with decreased expression of vascular endothelial growth factor (VEGF) and its receptor VEGFR2 in endothelial cells, was observed. Taken together, these results suggest diminished atherosclerotic progression in cavernous tissue. However, functional studies will be necessary to elucidate if catechin-rich beverages are useful compounds in the prevention of deleterious vascular events associated with ED. It was also demonstrated that regular consumption of catechins reduces atherosclerotic progression and mortality due to cardiovascular disease. The results reported here suggest diminished atherosclerotic progression in cavernous tissue in aged rats following chronic ingestion of catechin-rich beverages.

Global experiences with vardenafil in men with erectile dysfunction and underlying conditions

OBJECTIVE

Vardenafil has demonstrated efficacy for the pharmacological management of erectile dysfunction (ED). Accumulating evidence suggests that ED is frequently associated with underlying cardiovascular and metabolic conditions which are thought to be involved in the aetiology of ED. The present review aims to summarise and discuss the available evidence for the efficacy, safety and tolerability of vardenafil in patients with underlying conditions including diabetes, hypertension and dyslipidaemia.

METHODS

Relevant articles were identified through a PubMed search of clinical trials and postmarketing surveillance studies of vardenafil in patients with ED including those with diabetes, hypertension and dyslipidaemia.

RESULTS

Across all trials, vardenafil showed good efficacy for the treatment of ED in patients with diabetes, hypertension and dyslipidaemia. Vardenafil also showed a favourable safety and tolerability profile. The concomitant use of medication to treat hypertension or dyslipidaemia was not associated with an increase in adverse events following vardenafil treatment.

CONCLUSIONS

The prevalence of both diagnosed and undiagnosed underlying conditions is high among men with ED. The evidence presented in this review suggests that vardenafil is efficacious and well tolerated in patients with ED and diabetes, hypertension and/or dyslipidaemia and can be recommended as first-line treatment for ED in patients with these conditions.

Multiple episodes in children and adolescents with bipolar disorder: comorbidity, hospitalization, and treatment (data from a cohort of 8,129 patients of a national managed care database)

OBJECTIVE

The purpose of this study was to delineate the prevalence, demographic characteristics, comorbidity, hospitalization, and medication use of a large cohort of patients with and without multiple episodes per year. We hypothesized that children and adolescents with multiple episodes per year would have a higher comorbidity and require more hospitalizations and pharmacological treatment than their counterparts without multiple episodes.

METHODS

Analysis was conducted on a cohort of 8,129 children and adolescents patients (< or = 18 y.o.) with bipolar disorders (BD), from the Integrated Healthcare Information Services (IHCIS) identified from June 30, 2000 to July 1, 2003. Demographics variables, type of hospitalization, and psychotropic medication used in the year of follow-up were compared between children and adolescents with multiple and those without multiple episodes per year.

RESULTS

Included were 58 patients with multiple episodes (defined as: > or = 4 or more reports of inpatient treatment for any affective disorders per year) and 8,071 without multiple episodes. Children and adolescents with multiple episodes versus those without multiple episodes were differentiated as follows: more comorbid attention deficit disorder (ADD) (80.9% versus 29.4%) (chi2 = 70.61, df = 1, p < 0.0001); higher rate of hospital admission for depression (12.1% vs. 1.8%, chi2 = 27.86, df = 1, p < 0.0001); for other psychiatric conditions (48.3% vs. 11.2, chi2 = 74.47, df = 1, p < 0.0001) and for medical conditions (22.4% vs. 3.9%, chi2 = 46.26, df = 1, p < 0.0001). Patients with multiple episodes per year were more likely than those without multiple episodes to be given mood stabilizers (91.4% vs. 60.3%, chi2 = 22.02, df = 1, p < 0.0001), antidepressants (79.3% vs. 59.2%, chi2 = 8.82, df = 1, p = .0003), and antipsychotics (89.7% vs. 45.8%, chi2 = 42.91, df = 1, p < 0.0001). The use of stimulants did not differ between the two groups (24.1% vs. 23.0%), chi2 = 0.02, df = 1, p = 0.96).

CONCLUSIONS

Our findings support previous studies demonstrating that children and adolescents with multiple episodes per year present a higher comorbidity and require more hospitalizations and pharmacological treatment than those without multiple episodes. The diagnosis and treatment of children and adolescents with BD will have to take into account the high comorbidity of ADD mainly in children and adolescents with multiple episodes. Future prospective studies will help to better characterize the impact of multiple episodes in the course of pediatric BD and facilitate appropriate treatment strategies.

Erectile dysfunction: does insulin resistance play a part?

OBJECTIVE

To review MEDLINE literature for correlations between insulin resistance and erectile dysfunction (ED).

DESIGN

MEDLINE literature review (1966 to present).

SETTING

Academic medical center.

PATIENT(S)

None.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

None.

RESULT(S)

Erectile dysfunction affects more than half of men over the age of 40. Fortunately, most men with ED can be successfully treated with phosphodiesterase 5A (PDE-5) inhibitors, which up-regulate the vasodilatory effects of nitric oxide (NO). Insulin resistance affects 25% of U.S. adults and increases to a 60% occurrence in individuals who are overweight. Endothelial dysfunction, which is associated with insulin resistance states, can cause disturbances in the subcellular signaling pathways required for NO production. Because endothelial production of NO and insulin sensitivity are positively related in healthy humans, the relationships among insulin resistance, NO, and ED are the target of this review of MEDLINE literature.

CONCLUSION(S)

Insulin resistance states are characterized by defective vascular NO production and impaired insulin-induced vasodilation, both of which are likely to cause ED. Diagnosing and treating insulin resistance should be part of the initial management plan for ED. Future studies concerning the cause and effect relationship of insulin resistance and ED should be implemented.

Severity of coronary artery disease and symptoms of erectile dysfunction in males with a positive exercise treadmill test

AIM

The objective of this study is to investigate the significance of erectile dysfunction in males with a positive exercise treadmill test (ETT) to predict the severity of coronary artery disease (CAD).

MATERIALS AND METHOD

With no previous marked CAD, and applying to our clinic with chest pain, 105 male patients (mean age: 56 +/- 8 years) underwent coronary angiography after the ETT. These patients met our criteria and were included in our study. All patients were requested to complete a brief, 5-item form by the International Index of Erectile Function, and the Sexual Health Inventory for Men (SHIM), and were classified into four groups according to coronary angiography results as follows: normal coronary artery (NCA), single-vessel CAD (1 V), two-vessel CAD (2 V) and three-vessel CAD (3 V). The relation between SHIM scores and the number of arteries with significant lesions was evaluated.

RESULTS

The median SHIM score was found to be significantly lower in both the 2 V, 15 (IQR: 12-20) and 3 V, 13 (IQR: 11-16) groups compared to the NCA, 22 (IQR: 17-23) and the 1 V, 22 (IQR: 17-23) groups (P < 0.05). Grouped as group I (NCA + 1 V) and group II (2 V + 3 V), the patients were recompared. The SHIM score is an independent parameter to define the presence of significant lesions in two or more coronary arteries (odds ratio, 0.84; 95% CI, 0.73-0.97; P = 0.019).

CONCLUSION

The fact that the SHIM score is <18 in ETT positive males may suggest that the probability of multivessel CAD should be high.

ED2: erectile dysfunction = endothelial dysfunction

Erectile dysfunction (ED) is a common condition in men, and increases with age. Cardiovascular disease (CVD) is the leading cause of death in men and also increases in prevalence with advancing years. The common link between the two conditions is endothelial dysfunction that leads to vascular insufficiency of the coronary and penile arteries. Because the penile arteries are smaller, symptoms of ED may precede those of CVD by several years. It is logical, therefore, that a patient complaining of ED should alert the physician to look for cardiovascular risk factors. Early treatment of these risk factors may help to prevent or retard symptoms of vascular insufficiency.

Sexual function in hypertensive patients receiving treatment

In many forms of erectile dysfunction (ED), cardiovascular risk factors, in particular arterial hypertension, seem to be extremely common. While causes for ED are related to a broad spectrum of diseases, a generalized vascular process seems to be the underlying mechanism in many patients, which in a large portion of clinical cases involves endothelial dysfunction, ie, inadequate vasodilation in response to endothelium-dependent stimuli, both in the systemic vasculature and the penile arteries. Due to this close association of cardiovascular disease and ED, patients with ED should be evaluated as to whether they may suffer from cardiovascular risk factors including hypertension, cardiovascular disease or silent myocardial ischemia. On the other hand, cardiovascular patients, seeking treatment of ED, must be evaluated in order to decide whether treatment of ED or sexual activity can be recommended without significantly increased cardiac risk. The guideline from the first and second Princeton Consensus Conference may be applied in this context. While consequent treatment of cardiovascular risk factors should be accomplished in these patients, many antihypertensive drugs may worsen sexual function as a drug specific side-effect. Importantly, effective treatment for arterial hypertension should not be discontinued as hypertension itself may contribute to altered sexual functioning; to the contrary, alternative antihypertensive regimes should be administered with individually tailored drug regimes with minimal side-effects on sexual function. When phosphodiesterase-5 inhibitors, such as sildenafil, tadalafil and vardenafil, are prescribed to hypertensive patients on antihypertensive drugs, these combinations of antihypertensive drugs and phosphodiesterase 5 are usually well tolerated, provided there is a baseline blood pressure of at least 90/60 mmHg. However, there are two exceptions: nitric oxide donors and α-adrenoceptor blockers. Any drug serving as a nitric oxide donor (nitrates) is absolutely contraindicated in combination with phosphodiesterase 5 inhibitors, due to significant, potentially life threatening hypotension. Also, α-adrenoceptor blockers, such as doxazosin, terazosin and tamsulosin, should only be combined with phosphodiesterase 5 inhibitors with special caution and close monitoring of blood pressure.

Sexual sequelae of general medical disorders

That sexual symptoms can signal serious underlying disease confirms the importance of sexual enquiry as an integral component of medical assessment. Data on sexual function are sparse in some medical specialties. However, increased scientific understanding of the central and peripheral physiology of sexual response could help to identify the pathophysiology of sexual dysfunction from disease and medical interventions, and also to ameliorate or prevent some dysfunctions. Many common general medical disorders have negative effects on desire, arousal, orgasm, ejaculation, and freedom from pain during sex. Chronic disease also interferes indirectly with sexual function, by altering relationships and self-image and causing fatigue, pain, disfigurement, and dependency. Current approaches to assessment of sexual dysfunction are based on models that combine psychological and biological aspects.

Clues to Cardiovascular Risk: An Office-Based Approach

Current tools for predicting coronary heart disease risk in the asymptomatic patient fall into 2 major categories: traditional population-based models and noninvasive imaging techniques. Population-based models that estimate cardiovascular risk are powerful clinical tools but do not utilize a large volume of patient-specific data that are readily available to the clinician and may help to identify at-risk patients. The use of high-technology noninvasive imaging has not been consistently validated and clinicians or patients often lack the resources for such testing. This paper reviews several commonly encountered historical, physical, radiologic, laboratory, and electrocardiographic markers of increased cardiovascular risk that may enhance clinicians' ability to identify individual patients at increased risk for coronary heart disease.

Erectile Dysfunction in Heart Failure Patients

Chronic heart failure (HF) and erectile dysfunction (ED) are 2 highly prevalent disorders that frequently occur concomitantly. Coronary artery disease, HF, and ED share several common risk factors, including diabetes mellitus, hypertension, smoking, and dyslipidemia. Additionally, the distinct physiologic sequelae of HF create unique organic and psychologic factors contributing to ED in this patient population. Standard HF therapy with beta-receptor blockers, digoxin and thiazide diuretics may worsen sexual dysfunction owing to medication side effects. This may, in turn, lead to noncompliance in misguided efforts to retain satisfactory sexual activity, with secondary worsening of cardiac capacity. This review describes the unique aspects of ED in the HF population.

A retrospective study of the relationship between biomarkers of atherosclerosis and erectile dysfunction in 988 men

Erectile dysfunction (ED) is associated with clinical atherosclerosis and several atherosclerotic risk factors including smoking, hypertension, dyslipidemia, diabetes mellitus, obesity and sedentary lifestyle. Clinical atherosclerosis is also associated with these same risk factors and with biomarkers of inflammation, thrombosis, endothelial cell activation. We evaluated the cross-sectional association between the degree of ED and levels of atherosclerotic biomarkers. A subcohort of 988 US male health professionals between the ages 46 and 81 years as part of an ongoing epidemiologic study had atherosclerotic biomarkers measured from blood collected in 1994-1995. These same men had in 2000, been retrospectively asked about erectile function in 1995 and in 2000. Biennial questionnaires since 1986 assessed medical conditions, medications, smoking, physical activity, body mass index, alcohol intake. The retrospective assessment of erectile function in 2000 for 1995 in these 988 men ranged from very good - 28.2%, good - 25.1%, fair - 19.2%, poor - 13.6%, to very poor - 13.9%. Men with poor to very poor erectile function compared to men with good and very good erectile function had 2.9 the odds of having elevated Factor VII levels (P=0.03), 1.9 times the odds of having elevated vascular cell adhesion molecule (P=0.13) and 2.0 times the odds of having elevated intracellular adhesion molecule (P=0.06) and 2.1 times the odds of having elevated total cholesterol/high-density lipoprotein ratio (P=0.02) comparing the top to bottom quintiles for each atherosclerotic biomarker after multivariate adjustment. Lipoprotein(a), homocysteine, interleukin-6 and tumor necrosis factor receptor, C-reactive protein and fibrinogen were not associated with the degree of erectile function after adjustment. We conclude that selected biomarkers for endothelial function, thrombosis and dyslipidemia but not inflammation are associated with the degree of ED in this cross-sectional analysis. Future studies evaluating the prospective association of ED, endothelial function and cardiovascular disease appear warranted.

Pharmacology of erectile dysfunction in man

Erectile dysfunction (ED) is defined as the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual activity (2nd International Consultation on Sexual Dysfunction-Paris, June 28th-July 1st, 2003). Following the discovery and introduction of sildenafil, research on the mechanisms underlying penile erection has had an enormous boost and many preclinical and clinical papers have been published in the last 5 years. This review is structured in order to give the reader an overview of the clinical and preclinical data available on the peripheral regulation of and the mediators involved in human penile erection. The most widely accepted risk factors for ED are discussed. The article is focused on human data, and the safety and effectiveness of the 3 commercially available Phosphodiesterase-5 (PDE5) inhibitors used to treat ED are also discussed.

Association between erectile dysfunction and coronary artery disease: Matching the right target with the right test in the right patient

INTRODUCTION

Evidence is accumulating in favour of a link between erectile dysfunction (ED) and coronary artery disease (CAD). This review attempts to identify which patients, among those with ED and no cardiovascular (CV) disease, should be screened for early, subclinical CAD, which coronary targets should be investigated, and which tests should be used.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1988 to January 2006.

RESULTS

Initial screening of patients with ED may adopt risk assessment office-based approaches to score patients into low, intermediate, or high risk of future cardiovascular events. Attention should be drawn to patients at intermediate risk. Targets for the assessment of subclinical CAD in this subset of patients should include both obstructive (flow-limiting) and nonobstructive (non-flow-limiting) CAD. Some tests address obstructive atherosclerosis by directly assessing coronary flow reserve (i.e., standard exercise stress test, rest/stress myocardial scintigraphy or echocardiography). Other tests are general measures of atherosclerosis burden (not necessarily obstructive) either in the coronary circulation (i.e., coronary calcium score by electron-beam computed tomography), or in extracoronary vessels (i.e., ankle brachial index, carotid intima-media thickness by B-mode ultrasound) as surrogate markers of CAD. Although a systematic use of these measures of nonobstructive atherosclerosis burden has not yet been recommended in the guidelines for coronary risk assessment, their use is progressively being extended from the research area to clinical practice.

CONCLUSIONS

ED is definitely a vascular disorder and all men with ED should be considered at risk of CV disease until proven otherwise. Available risk assessment charts should be used to stratify (low, intermediate, and high) the coronary risk score in each patient with ED.

The phosphodiesterase-5 inhibitor tadalafil reduces myocardial infarct size

The aim of this study was to determine, in an animal model, the effects of tadalafil on myocardial infarct size (IS), hemodynamics and regional myocardial blood flow after myocardial ischemia and reperfusion. Patients with erectile dysfunction (ED) often have risk factors for coronary artery disease. Tadalafil, a long-acting inhibitor of the enzyme phosphodiesterase-5 (PDE5), is used for the treatment of ED; there are no previous data regarding tadalafil in the setting of coronary artery occlusion (CAO). Sprague-Dawley male rats were treated with tadalafil or vehicle (10 mg/kg, by gastric gavage), 2 h before a 30 min CAO. Heart rate was comparable between tadalafil and control groups. Tadalafil reduced mean arterial pressure (P=0.009), systolic (P=0.035) and diastolic (P=0.009) blood pressures during ischemia/reperfusion. Tadalafil significantly reduced IS (42+/-2%) versus controls (54+/-3%) (P=0.006). For the first time, we showed that the PDE5 inhibitor, tadalafil, was well tolerated and cardioprotective in the setting of an experimental myocardial infarction, by substantially reducing ischemic cell death.

Erectile dysfunction and coronary atherothrombosis in diabetic patients: pathophysiology, clinical features and treatment

The current review reports recent data available in the literature on the prevalence of erectile dysfunction and the association of erectile dysfunction with overt and silent coronary artery disease in patients with diabetes mellitus. The mechanisms by which erectile dysfunction is associated with coronary artery disease and potential clinical implications of this association have been extensively analysed. In particular, the role of endothelial dysfunction in the pathophysiology of erectile dysfunction and the potential clinical usefulness of erectile dysfunction to identify diabetic patients with silent coronary artery disease have been outlined. Finally, recent guidelines on the treatment of erectile dysfunction with phosphodiesterase-5 inhibitors in diabetic patients with and without coronary artery disease have been reported and discussed.

Comorbid conditions in men with ED before and after ED diagnosis: a retrospective database study

Although erectile dysfunction (ED) has been considered a complication of other medical conditions, clinicians and researchers suggest that ED may serve as a clinical marker of vascular health. This retrospective claims study examined the prevalence of predefined comorbid conditions in men with ED (N=301 994) in the 12 months before and the 6 months following ED diagnosis. Consistent with previous research, comorbid conditions were prevalent among men with ED. Comorbid conditions were most often diagnosed before an ED diagnosis, although new diagnoses in the 6 months following an ED diagnosis were common and occured more frequently than new diagnoses in a matched sample of men without ED during the same period. Differences by age, region and insurance coverage for ED medications were also examined. Findings support previous research that suggests ED may serve as a marker for previously undetected comorbid conditions.