Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel

The impact of a neuromuscular rehabilitation programme on the quality of life of patients with acute coronary syndrome and its relationship with sexual dysfunction: a randomised controlled trial

PURPOSE

Many patients with acute coronary syndrome experience problematic or altered sexual function. This aspect of the disease is frequently ignored or overlooked by the healthcare community even though it can strongly influence health-related patient quality of life (HRQoL). Thus, the aim of this study was to compare the effects of a specific cardiac rehabilitation programme focused on aerobic and neuromuscular strength-resistance training to those of a classic rehabilitation programme, both in terms of HRQoL and erectile dysfunction in patients with acute coronary syndrome.

METHODS

This study reports both secondary and unregistered outcomes from a double-blinded, randomised, and controlled clinical trial. The proposed intervention was based on the completion of a 20-session (10-week) cardiac rehabilitation programme for patients with cardiovascular disease. The patient cohort had been diagnosed with acute coronary syndrome and was recruited at the Cardiology Service of a private tertiary hospital. The outcomes assessed in this study were HRQoL and erectile disfunction assessed at baseline, after the intervention, and at a 6-month follow-up.

RESULTS

A total of 30 participants were randomly allocated to each study arm. The results of the two-way mixed ANOVAs showed significant group × time interactions for all the outcome measures (EQ-5D_index, p = 0.004; EQ-5D_VAS, p = 0.017; QLMI-Q, p ≤ 0.001; and IIEF-5, p = 0.001).

CONCLUSION

The neuromuscular strength training programme was more effective than the classic strength training programme in terms of increasing the HRQoL and improving erectile dysfunction in patients following acute coronary syndrome, with differences still remaining between these groups at the 6-month follow-up.

Let’s talk about sex: exploring factors influencing the discussion of sexual health among chronically Ill patients in general practice

Background

Chronic diseases are often associated with sexual dysfunction (SD). Little is known about the practice patterns of general practitioners (GPs) regarding sexual care for chronically ill patients. Therefore, the aim of this study was to examine; to what extent GPs discuss SD with chronically ill patients; the barriers that may stop them; and the factors associated with discussing SD.

Methods

A cross-sectional survey using a 58-item questionnaire was sent to 604 Dutch GPs. Descriptive statistics and associations were used for analysis of the data.

Results

Nearly 58% (n = 350) of all GPs approached gave a response and 204 questionnaires were analysable (33.8%). Almost 60% of respondents considered discussing SD with patients important (58.3%, n = 119). During the first consultation, 67.5% (n = 137) of the GPs reported that they never discussed SD. The most important barrier stopping them was lack of time (51.7%, n = 104). The majority (90.2%, n = 184) stated that the GP was responsible for addressing SD; 70.1% (n = 143) indicated that the GP practice somatic care nurse (GPN) was also responsible. Nearly 80% (n = 161) of respondents were unaware of agreements within the practice on accountability for discussing SD. This group discussed SD less often during first and follow-up consults (p = 0.002 and p < 0.001, respectively). Of the respondents, 61.5% (n = 116) felt that they had received insufficient education in SD and 74.6% (n = 150) stated that the subject is seldom discussed during training. Approximately 62% of the GPs (n = 123) wanted to increase their knowledge, preferably through extra training. According to 53.2% of the GPs (n = 107) it was important to improve the knowledge of the GPN. The most frequently mentioned tool that could help improve the conversation about SD was the availability of information brochures for patients (n = 123, 60.3%).

Conclusions

This study indicates that Dutch GPs do not discuss SD with chronically ill patients routinely, mainly due to lack of time. An efficient tool is needed to enable GPs to address SD in a time-saving manner. Increased availability of informational materials, agreements on accountability within GP practices, and extra training for the GPs and GPNs could improve the discussion of SD.

Sex-Related Differences in Pharmacological Response to CNS Drugs: A Narrative Review

In the last decades, both animal and human studies have neglected female subjects with the aim of evading a theorized intricacy of feminine hormonal status. However, clinical experience proves that pharmacological response may vary between the two sexes since pathophysiological dissimilarities between men and women significantly influence the pharmacokinetics and pharmacodynamics of drugs. Sex-related differences in central nervous system (CNS) medication are particularly challenging to assess due to the complexity of disease manifestation, drugs’ intricate mechanisms of action, and lack of trustworthy means of evaluating the clinical response to medication. Although many studies showed contrary results, it appears to be a general tendency towards a certain sex-related difference in each pharmacological class. Broadly, opioids seem to produce better analgesia in women especially when they are administered for a prolonged period of time. On the other hand, respiratory and gastrointestinal adverse drug reactions (ADRs) following morphine therapy are more prevalent among female patients. Regarding antidepressants, studies suggest that males might respond better to tricyclic antidepressants (TCAs), whereas females prefer selective serotonin reuptake inhibitors (SSRI), probably due to their tolerance to particular ADRs. In general, studies missed spotting any significant sex-related differences in the therapeutic effect of antiepileptic drugs (AED), but ADRs have sex variations in conjunction with sex hormones’ metabolism. On the subject of antipsychotic therapy, women appear to have a superior response to this pharmacological class, although there are also studies claiming the opposite. However, it seems that reported sex-related differences regarding ADRs are steadier: women are more at risk of developing various side effects, such as metabolic dysfunctions, cardiovascular disorders, and hyperprolactinemia. Taking all of the above into account, it seems that response to CNS drugs might be occasionally influenced by sex as a biological variable. Nonetheless, although for each pharmacological class, studies generally converge to a certain pattern, opposite outcomes are standing in the way of a clear consensus. Hence, the fact that so many studies are yielding conflicting results emphasizes once again the need to address sex-related differences in pharmacological response to drugs.

Sexual Activity After Acute Coronary Syndrome: A Qualitative Approach to Patient and Partner Experiences

Little is known about how best to support both patients and their partners in the reengagement of sexual activity (SA) after acute coronary syndrome (ACS), with sparse direct data from the partner on their needs and concerns in the area of SA support.

Considerations for prescribing pharmacotherapy for the treatment of erectile dysfunction

Introduction: The effectiveness of phosphodiesterase type 5 inhibitors (PDE5i) in treating erectile dysfunction (ED) creates a new field of both medical practice and pharmaceutical manufacturing. Both paved the way for emerging minimally invasive therapies to restore male sexual function. However, what is the best drug to achieve the optimum outcome is still a challenging question to be answered.Areas covered: The general viewpoint of matching the pharmacotherapeutic characteristics with the patient's medical, social, and psychological variables, in order to balance between efficacy and safety. Several studies had investigated considerations for preference and long-term adherence for PDE5i. However, a thorough investigation of considerations for prescribing ED pharmacotherapy is still lacking in the literature. This is the aim of this manuscript.Expert opinion: Several issues should be considered in the planning of ED management such as the patient's and partner's expectations, etiologic considerations, performance status, safety, adverse effects, ease of administration, compliance, bad experiences with previous treatment, availability, cost, social factors, satisfaction, and finally, regimen considerations. Addressing the patient's and partner's individual needs help to tailoring treatment in order to minimize compromises and optimize gains.

Sexual Activity After Myocardial Revascularization Surgery

After a cardiovascular event, patients and their families often face numerous changes in their lives. Poorly addressing physical and psychological challenges can lead to an impaired quality of life. Sexuality is an important quality of life aspect to many patients and couples who can be negatively affected by a cardiovascular event. Sexual health requires a positive and respectful approach to sexuality and sexual relationships. Time to resume sexual activity after myocardial revascularization surgery is a gap in cardiologic practice. We know from literature that coronary patients have decreased sexual activity. There are barriers from the medical environment such as lack of knowledge, confidence and training, and many others that arise from the patient's perspective, which do not allow generating a space to address sexual problems. This review aims to familiarize and update cardiologists, providing knowledge and resources to face the impact of myocardial revascularization surgery on the quality of sexual life, promoting multidisciplinary management among doctors and other health professionals.

Sexual Activity After Myocardial Revascularization Surgery

After a cardiovascular event, patients and their families often face numerous changes in their lives. Poorly addressing physical and psychological challenges can lead to an impaired quality of life. Sexuality is an aspect of quality of life that is important to many patients and couples who can be negatively affected by a cardiovascular event. Sexual health requires a positive and respectful approach to sexuality and sexual relationships. The timing of return to sexual activity after myocardial revascularization surgery is a gap in cardiology practice. We know from the literature that coronary patients have a decrease in sexual activity. There are barriers from the medical environment such as lack of knowledge, confidence, and training, and many others that arise from the patient's perspective, which do not allow generating a space to address sexual problems. This review aims to familiarize and update the cardiologist, bringing knowledge and resources closer to the impact of myocardial revascularization surgery on the quality of sexual life of patients, always encouraging multidisciplinary management among doctors and other professionals in health.

Love Death-A Retrospective and Prospective Follow-Up Mortality Study Over 45 Years

BACKGROUND

Although sexual activity can cause moderate stress, it can cause natural death in individuals with pre-existing illness. The aim of this study was to identify additional pre-existing health problems, sexual practices, and potential circumstances that may trigger fatal events.

METHODS

This medicolegal postmortem, retrospective, and prospective study is based on data of autopsies performed at the Institute of Legal Medicine of the University hospital, Goethe-University, Frankfurt/Main, Germany.

OUTCOMES

Identification of pre-existing health problems, sexual practices, and potential circumstances than could trigger fatal events.

RESULTS

From 1972 to 2016 (45 years) approximately 38,000 medicolegal autopsies were performed, of which 99 cases of natural death were connected to sexual activities (0.26%). Except for eight women, men represented most cases. The women's mean age was 45 years (median = 45) and the men's mean age was 57.2 years (median = 57). Causes of death were coronary heart disease (n = 28), myocardial infarction (n = 21) and reinfarction (n = 17), cerebral hemorrhage (n = 12), rupture of aortic aneurysms (n = 8), cardiomyopathy (n = 8), acute heart failure (n = 2), sudden cardiac arrest (n = 1), myocarditis (n = 1), and a combination of post myocardial infarction and cocaine intoxication (n = 1). Most cases showed increased heart weights and body mass indices. Death occurred mainly during the summer and spring and in the home of the deceased. If sexual partners were identified, 34 men died during or after sexual contact with a female prostitute, two cases at least two female prostitutes. Nine men died during or after sexual intercourse with their wife, in seven cases the sexual partner was a mistress, and in four cases the life partner. Five men died during homosexual contacts. Based on the situation 30 men were found in, death occurred during masturbation. Of the women, five died during intercourse with the life partner, two died during intercourse with a lover or friend, and in one case no information was provided.

CLINICAL TRANSLATION

Natural deaths connected with sexual activity appear to be associated with male sex and pre-existing cardiovascular disorders. Most cases recorded occurred with mistresses, prostitutes, or during masturbation. If death occurs, the spouse or life partner might need psychological support.

STRENGTH AND LIMITATIONS

To our knowledge, the present study contains the largest collection of postmortem data on natural deaths connected with sexual activities. However, the cases presented were of forensic interest; a larger number of undetected cases especially in the marital or stable relationship sector must be assumed.

CONCLUSION

Patients should be informed about the circumstances that could trigger the "love death." Lange L, Zedler B, Verhoff MA, Parzeller M. Love Death-A Retrospective and Prospective Follow-Up Mortality Study Over 45 Years. J Sex Med 2017;14:1226-1231.

Attitudes and Performance of Cardiologists Toward Sexual Issues in Cardiovascular Patients

Introduction

The aim of the present study was to evaluate the attitudes and performance of cardiologists regarding sexual issues in patients with cardiovascular diseases.

Methods

A nationwide survey was conducted in a sample of cardiologists, representative of Iranian cardiologists, in 2015.

Main Outcome Measures

Appropriate questionnaires were developed and used to ask participants about their attitudes, performance, and barriers regarding discussing sexual issues with patients with cardiovascular disease.

Results

The study population consisted of 202 cardiologists (138 men and 63 women) with a mean age of 44.25 years (SD = 8.45). Overall, 93.15% of cardiologists agreed with the importance of discussing sexual issues with their patients with cardiovascular diseases. Almost 76.7% of cardiologists agreed they had a responsibility to deal with patients' sexual problems, and 79.9% of them were aware of the association of cardiovascular disease with sexual problems of cardiac patients, but only 33% of them were confident in their knowledge and skills in this regard. Only 10.6% of cardiologists reported they frequently or always assessed sexual problems with their patients, but 51.50% of them stated they were responding to patients' questions about sexual problems. There was a significant association between performance and responsibility.

Conclusion

The results of this study indicate a gap between cardiologist's attitudes and their actual performance and that their professional responsibility to address patients' sexual issues is a significant parameter for better performance.

Basic Science Evidence for the Link Between Erectile Dysfunction and Cardiometabolic Dysfunction

INTRODUCTION

Although clinical evidence supports an association between cardiovascular/metabolic diseases (CVMD) and erectile dysfunction (ED), scientific evidence for this link is incompletely elucidated.

AIM

This study aims to provide scientific evidence for the link between CVMD and ED.

METHODS

In this White Paper, the Basic Science Committee of the Sexual Medicine Society of North America assessed the current literature on basic scientific support for a mechanistic link between ED and CVMD, and deficiencies in this regard with a critical assessment of current preclinical models of disease.

RESULTS

A link exists between ED and CVMD on several grounds: the endothelium (endothelium-derived nitric oxide and oxidative stress imbalance); smooth muscle (SM) (SM abundance and altered molecular regulation of SM contractility); autonomic innervation (autonomic neuropathy and decreased neuronal-derived nitric oxide); hormones (impaired testosterone release and actions); and metabolics (hyperlipidemia, advanced glycation end product formation).

CONCLUSION

Basic science evidence supports the link between ED and CVMD. The Committee also highlighted gaps in knowledge and provided recommendations for guiding further scientific study defining this risk relationship. This endeavor serves to develop novel strategic directions for therapeutic interventions.

Erectile dysfunction and hypertension: impact on cardiovascular risk and treatment

Erectile dysfunction (ED) is a common complaint in hypertensive men and can represent a systemic vascular disease, an adverse effect of antihypertensive medication or a frequent concern that may impair drug compliance. ED has been considered an early marker of cardiovascular disease. The connection between both conditions seems to be located in the endothelium, which may become unable to generate the necessary dilatation in penile vascular bed in response to sexual excitement, producing persistent impairment in erection. On the other hand, the real influence of antihypertensive drugs in erectile function still deserves discussion. Therefore, regardless of ED mechanism in hypertension, early diagnosis and correct approach of sexual life represent an important step of cardiovascular evaluation which certainly contributes for a better choice of hypertension treatment, preventing some complications and restoring the quality of life.

The difference of heart rate recovery between males with and without erectile dysfunction

AIM

In this study, we aimed to investigate the relationship between heart rate recovery (HRR) time and Chronotropic Index (CHIND) parameters, which also reflect autonomic function, after exercise stress test (EST) in males with or without erectile dysfunction (ED), and we investigated the relationship between HRR and CHIND and serum steroid hormone levels.

MATERIAL AND METHODS

A total of 135 participants (mean age: 45.0 +/- 11.8 years) were enrolled into the study. Detailed biochemical and hormonal analyses, 12-lead electrocardiography and EST (Treadmill) were performed in all participants. Erectile function was assessed using the International Index of Erectile Function (IIEF) questionnaire form. Patients were categorized into two groups according to their IIEF scores as ED (+) (IIEF < 26) and ED (-) (IIEF > or = 26). Afterward, statistical analyses were performed to evaluate the correlations between ED and HRR and CHIND.

RESULTS

A total of 65 patients were ED (+) (mean age 44.9 +/- 6.4 years), while 70 patients (mean age 43.7 +/- 7.7 years) had normal erectile status. There were statistically significant differences in CHIND (P = 0.015) and HRR time (P = 0.037) between ED (+) and ED (-) patients. In correlation analysis, IIEF score was found positively correlated with HRR and metabolic equivalent (MET) values (r(HRR)= 0.293, P = 0.037; r(METs)= 0.388, P = 0.011, respectively). Linear regression analysis revealed that METs value and total exercise time had a more linear relationship with IIEF score compared to the other EST parameters (p(METs)= 0.002 and p(TET)= 0.015, respectively).

CONCLUSION

Chronotropic incompetence and dynamic postexercise autonomic dysfunction are present in ED patients. This condition may reflect decreased functional capacity and exercise intolerance in these patients.

Factors affecting self-reported sexuality in men with obstructive sleep apnea syndrome

INTRODUCTION

Obstructive sleep apnea syndrome (OSAS) is known to induce erectile dysfunction and to reduce overall sexual satisfaction in affected men. Data on the effects of disease severity and other contributing factors such as the age of the patient are missing.

AIM

To compare self-reported sexuality in men with newly diagnosed sleep apnea with a group of disease-free men, and to evaluate the impact of disease severity and age on the response pattern.

MAIN OUTCOME MEASURES

Self-reported erectile function, desire, and frequencies for petting, tenderness, masturbation, sexual intercourse, and overall satisfaction with sexuality over a recall period of 3 months.

METHODS

A prospective survey in men admitted to a multidisciplinary sleep center using a standardized validated German questionnaire.

RESULTS

One hundred-sixteen men 51.1 +/- 11.4 years (mean +/- standard deviation) with OSAS (OSAS+) and 42 men age 46.6 +/- 13.7 years without OSAS (OSAS-) completed the survey. OSAS+ men were older (P = 0.01) and more often divorced (P = 0.048). OSAS was significantly associated with erection problems (P = 0.024) and decreased overall sexual satisfaction (P = 0.04). In contrast disease severity did affect masturbation frequency only (P = 0.02), whereas patient age affected erection (P = 0.001), and the desire for tenderness (P = 0.02) and intercourse (P = 0.0003).

CONCLUSION

Patient age might be a more important factor affecting sexuality in men with sleep apnea than the disease severity. Future studies assessing sexuality in men with OSAS should include age as an additional variable.

[Why and how to explore erectile function in patient with cardiovascular risk?]

Erectile dysfunction (ED) is a frequent disorder, which can be the first symptom of an underlying pathology such as cardiovascular diseases. Doctors should have a good understanding of erectile dysfunction and must be aware of the importance of detecting and investigating any erectile disorders. Detection of an erectile dysfunction induces to search underlying cardiovascular diseases, but also urinary symptoms, hormonal deprivation, mood and relational alterations and iatrogenous complications. Determination of erectile disorders therefore represents an excellent opportunity to conduct a work-up of this symptom, as an integral part of health policy.

What is the best predictor of postoperative erectile function in patients who will undergo coronary artery bypass surgery?

PURPOSE

The aim of this prospective study was to evaluate the impact of extracorporeal circulation and cross clamping period on erectile function in patients undergoing coronary artery bypass surgery (CABS).

MATERIALS AND METHODS

A total of 50 patients undergoing CABS were evaluated in this prospective study. Before and 6-12 months after the CABS, patients were interviewed for erectile dysfunction (ED) using the International Index of Erectile Function (IIEF). Scoring the IIEF domain of erectile function allowed the classification of each patient as having no (26-30), mild (17-25), moderate (11-16) or severe (0-10) ED. Patients with normal, mild and moderate ED score were designated as group A, B and C, respectively. Patients were classified in 2 groups to evaluate the impact of extracorporeal circulation and cross clamping period on erectile function in patients undergoing CABS. Patients who had no change in ED score in group A and patients who had recovery in group B were included in group1. Patients who had impaired ED score in group A and group B were included in group 2. All patients were also interviewed for sociodemographic and relevant medical history. Sociodemographic data were age, job, marital status, alcohol, narcotic and smoking habit. Medical risk factors were diabetes, hypertension and psychiatric disorders.

RESULTS

The mean age of patients included in the study were 46,6 (range 31-55). After the operation, 3 (7.5%) of 41 patients in group A had moderate, 1 (2.5%) had mild and 37 (90%) had no change in ED score. In group B, 2 (28%) of 7 patients had moderate, 4 (57%) had recovery in ED score, 1 had no change in ED score. There were only 2 patients in group C and 1 had severe, the other one had mild ED after the operation. The mean operation period was 234.8 m inutes in group 1 and 280 min in group 2. Cross clamping period and extracorporeal circulation of patients in group 1 and 2 were 33.2, 41.6 min and 54.7, 64.6 min, respectively. The groups were not statistically different with regard to mean operation, cross clamping and extracorporeal circulation period.

CONCLUSION

Preoperative erectile function seems to be the best predictor of postoperative erectile function in patients who will undergo CABS.

Sex and the heart

Erectile dysfunction (ED) is a highly prevalent and increasingly common, mainly vascular disorder. Most patients with chronic cardiovascular diseases experience decreased libido and frequency of sexual activity, as well as ED. Some unique organic and psychological factors contributing to ED have been identified in patients with underlying cardiovascular problems. Certain risk factors are common to the development of coronary artery disease, heart failure and ED, including diabetes mellitus, hypertension, smoking and dyslipidemia. Additionally, the use of medications such as beta blockers, digoxin and thiazide diuretics might eventually cause but more likely worsen sexual dysfunction. These unintended consequences can lead to medical noncompliance in misguided efforts to retain satisfactory sexual activity, and thereby worsen cardiovascular problems. Accordingly, it is important for physicians dealing with patients with cardiovascular diseases to address sexual concerns in their patients. After careful evaluation, most patients with stable cardiac disorders can resume sexual activity and/or can be treated for ED.

EAU Guidelines on erectile dysfunction: an update

The introduction of new oral therapies has completely changed the diagnostic and therapeutic approach to erectile dysfunction. A panel of experts in this field has developed guidelines for the clinical evaluation and treatment based on the review of available scientific information.

Phosphodiesterase type 5 inhibitor sildenafil citrate does not potentiate the vasodilative properties of nebivolol in rat aorta

BACKGROUND

Sildenafil citrate (SIL) is contraindicated in patients with coronary heart disease who are treated with nitric oxide (NO) donators such as organic nitrates, as it potentiates NO-mediated vasodilation. The present study investigated whether SIL also affects the vasodilatory effects of nebivolol (NEB), a selective beta1-adrenoceptor blocker with an additional, endothelium-dependent NO-liberating property, in comparison to the combination SIL/glycerol trinitrate (GTN).

METHODS AND RESULTS

Experiments were performed in isolated vessel rings of rat aorta (Wistar rats, 8-12 weeks), which had been pre-contracted with phenylephrine (10(-5) M). Isometric tension was measured by a force transducer, and cumulative concentration-response curves were obtained for each drug. The rank order of vasodilatory potency as measured by the concentration needed to achieve 50% relaxation (EC50) was GTN (0.08 microM) > SIL (1.25 microM) > or = NEB (3.5 microM). In the presence of both therapeutic (1 nM) and high (1 microM) concentrations of SIL, vasodilation of GTN was potentiated as indicated by a significant increase in vasodilatory potency (EC50 GTN + low SIL: 0.019 microM, EC50 GTN + high SIL: 0.002 microM; both P < 0.01 vs. GTN). In contrast, SIL did not potentiate the vasodilatory effect of NEB (EC50 NEB + low SIL: 5.01 microM, EC50 NEB + high SIL: 3.2 microM; n.s. vs. NEB).

CONCLUSIONS

These data demonstrate that SIL does not potentiate NEB-induced vasodilation in vitro. These findings indicate that the interaction between SIL and NO-donators/organic nitrates does not apply to the NO-liberating properties of NEB. Our findings suggest that SIL may safely be used in hypertensive patients treated with NEB.

Aetiology and management of male erectile dysfunction and female sexual dysfunction in patients with cardiovascular disease

The historical basis for understanding erectile function as a neurovascular phenomenon and the advance from fanciful to effective treatment of erectile dysfunction (ED) are reviewed, with emphasis on patients with cardiovascular disease (CVD). ED occurs in 60% of CVD patients by 40 years of age. Male ED and female sexual dysfunction (FSD) diminish quality of life and often warn of occult CVD. ED is often unrecognised but is readily diagnosed during a 5-minute interview using a truncated International Index of Erectile Function questionnaire. Erection of the penis and clitoral engorgement result from local, arousal-induced release of neuronal and endothelial-derived nitric oxide (NO). Arterial vasodilatation and relaxation of cavernosal smooth muscle cells cause arterial blood to flood trabecular spaces, compressing venous drainage, resulting in tumescence. Cyclic guanosine monophosphate (cGMP)-induced activation of protein kinase G mediates the effects of NO by enhancing calcium sequestration and activating large-conductance, calcium-sensitive K+ channels. Future treatment strategies will likely enhance these pathways. Phosphodiesterase-5 inhibitors (sildenafil, tadalafil and vardenafil) increase cGMP levels in erectile tissue. These agents are effective in 80% of CVD patients with ED and can be used safely, even in the presence of stable coronary disease or congestive heart failure, provided nitrates are avoided and patients do not have hypotension, severe aortic stenosis or evocable myocardial ischaemia. Second-line therapies (vacuum constrictor device and transurethral or intracavernosal prostaglandin E1) can also be used in CVD patients. Treatment of FSD and its relationship to CVD are less well established, but similarities to ED exist. ED can be prevented by reduction of CVD risk factors, exercise, weight loss and abstinence from smoking.

Impact of antihypertensive treatments on erectile responses in aging spontaneously hypertensive rats

OBJECTIVE

We previously demonstrated that brief, aggressive antihypertensive therapy recovered erectile function in 40-week-old spontaneously hypertensive rats (SHR). The present study examined the impact of antihypertensive and testosterone treatments on erectile function in aging SHR.

DESIGN AND METHODS

Centrally initiated erections were determined in response to apomorphine throughout. At 30 and 49 weeks, SHR were treated for 2 weeks with enalapril or hydralazine. A third more aggressive treatment (68 weeks) involved enalapril or losartan plus a low salt diet or a triple therapy (hydralazine, nifedipine, hydrochlorothiazide). In a separate study, cross-over kidney transplantations were performed between untreated and losartan-treated SHR. Arterial pressure was assessed post-transplantation using radio-telemetric transducers.

RESULTS

There was an age-related decrease in erections between 30 and 68 weeks (3.1 +/- 0.79 versus 0.2 +/- 0.38) that was not improved by testosterone administration. Early treatment with enalapril or hydralazine did not prevent this decline, although the second treatment resulted in significant improvements (enalapril, 0.8 +/- 0.70; hydralazine, 0.8 +/- 0.41 versus control, 0.3 +/- 0.60). A 2-week aggressive antihypertensive treatment at 68 weeks increased erections approximately two-fold, with the previously treated rats receiving triple therapy having markedly improved erectile responses (0.2 +/- 0.53 versus 1.1 +/- 1.67). In the transplantation study, previously losartan-treated SHR given an untreated kidney had higher arterial pressure but twice the number of erections in comparison with the SHR with lower arterial pressure resulting from transplanting a treated kidney.

CONCLUSIONS

Aggressive antihypertensive treatments may be more beneficial in improving erectile function in aged SHR, via an effect that appears to be tissue specific, and not based on changes in blood pressure.

Effect of sildenafil citrate on the cardiovascular system

Sildenafil citrate is a drug commonly used to manage erectile dysfunction. It is designated chemically as 1-[[3-(6,7-dihydro-1-methyl-7-oxo-3-propyl-1H -pyrazolo[4,3-d]pyrimidin-5-yl)-4 ethoxyphenyl] sulfonyl]-4-methylpiperazine citrate (C22H30N6(O4)S). It is a highly selective inhibitor of cyclic guanine monophosphate-specific phosphodiesterase type 5. In late March through mid-November 1998, the US Food and Drug Administration (FDA) published a report on 130 confirmed deaths among men (mean age, 64 years) who received prescriptions for sildenafil citrate, a period during which >6 million outpatient prescriptions (representing about 50 million tablets) were dispensed. The US FDA recently reported that significant cardiovascular events, including sudden cardiac death, have occurred in men with erectile dysfunction who were taking sildenafil citrate. These reports have raised concerns that sildenafil citrate may increase the risk of cardiovascular events, particularly fatal arrhythmias, in patients with cardiovascular disease. In the past few years, the cardiac electrophysiological effects of sildenafil citrate have been investigated extensively in both animal and clinical studies. According to extensive data available to date, sildenafil citrate has been shown to pose minimal cardiovascular risks to healthy people taking this drug. Some precautions are needed for patients with cardiovascular diseases. However, the only absolute contraindication for sildenafil citrate is the concurrent use of nitrates. This article is intended to review sildenafil citrate's cardiovascular effects, as well as current debates about its arrhythmogenic effects.

Safety and Tolerability of Oral Erectile Dysfunction Treatments in the Elderly

Erectile dysfunction (ED) is a common medical condition that affects the sexual life of millions of men worldwide. It is generally accepted that sexual function tends to decline with aging, which is often associated with a higher prevalence of sexual problems, including ED and loss of libido. As the mean age of men seeking medical help for sexual dysfunction continues to increase, it is important to assess the safety and tolerability of currently available medical treatments in elderly men, who often share other co-morbidities that should be carefully evaluated when any type of ED therapy is considered. With this aim in mind, a MEDLINE search was conducted from 1 January 1998 to 31 May 2004 to identify studies assessing the efficacy, safety and tolerability of treatments for ED in the elderly. Particular care was taken to assess the cardiovascular safety of oral drugs for ED in this subset of patients, who often have multiple cardiovascular risk factors which contribute to a complicated clinical scenario. The most important conclusion of the paper is that the high efficacy, reliability, safety and tolerability of oral ED treatments makes them appropriate first-line therapies for elderly patients with ED.

Erectile dysfunction and cardiovascular disease

Cardiovascular disease and erectile dysfunction (ED) are closely interrelated disease processes. Erectile dysfunction reportedly affects 10 million to 20 million men in the United States and more than 100 million men worldwide. Each year, about 500,000 persons in the United States survive a myocardial infarction, and an estimated 11 million have existing cardiovascular disease, making the issue of sexual function and cardiac disease relevant to many patients. We explore the relationship between ED and the presence of cardiovascular disease in the general population. We also review the prevalence and pathophysiological associations of ED and cardiovascular disease. The risks of sexual activity for patients with cardiovascular disease are discussed, as are prevention and treatment strategies for ED in this patient population.

The effect of vardenafil, a potent and highly selective phosphodiesterase-5 inhibitor for the treatment of erectile dysfunction, on the cardiovascular response to exercise in patients with coronary artery disease

OBJECTIVES

The effect of vardenafil, a potent and highly selective phosphodiesterase-5 (PDE5) inhibitor, on symptom-limited exercise time, time to first awareness of angina, and time to ischemic threshold (ST-segment depression > or =1 mm from baseline) during exercise tolerance testing (ETT) was examined in patients with stable coronary artery disease (CAD).

BACKGROUND

Erectile dysfunction (ED) is common among men with CAD. PDE5 inhibition is increasingly the preferred treatment option for ED. However, the effect of PDE5 inhibition on exercise-induced ischemia in CAD patients has received limited prospective evaluation.

METHODS

In this double-blind, crossover, single-dose multicenter study, 41 men with reproducible stable exertional angina due to ischemic CAD received vardenafil 10 mg or placebo, followed by ETT (5 to 10 metabolic equivalents [METS], Bruce protocol) 1 h postdose. Sublingual nitrate use was prohibited for > or =24 h pre- and postexercise study days. End points included symptom-limited treadmill exercise time, time to first awareness of angina, time to ischemic threshold, and safety.

RESULTS

Relative to placebo, vardenafil 10 mg did not alter exercise treadmill time (427 +/- 105 s vs. 433 +/- 109 s, p = 0.39), or time to first awareness of angina (292 +/- 110 s vs. 291 +/- 123 s, p = 0.59), but significantly prolonged time to ischemic threshold (334 +/- 108 s vs. 381 +/- 108, p = 0.0004). At peak exercise, vardenafil 10 mg did not alter blood pressure, heart rate, or rate-pressure product relative to placebo. The most common adverse events (facial flushing and headache) were of mild or moderate intensity, and short-lived.

CONCLUSIONS

Vardenafil 10 mg did not impair the ability of patients with stable CAD to exercise at levels equivalent or greater than that attained during sexual intercourse (average of 2.5 to 3.3 METS).

Cardiac drug-psychotropic drug update

This is an update from the report-Cardiac Drug and Psychotropic Drug Interactions: Significance and Recommendations-published in this journal in November-December 1999. As mentioned in that article there has been an explosion of new drugs both in psychiatry and cardiology without a sufficient understanding of their potential interactions. Also there is a need for methods to update drug interactions on an ongoing basis. This report describes: 1) examples of actual adverse interactions from clinical cases that move beyond some of the hypothesized contraindications included in the 2000 millennium publication; 2) confirmation of previous adverse interactions reported if they strengthen the earlier findings; 3) listing of new drugs, e.g., sildenafil (viagra) now commonly prescribed by psychiatrists and cardiologists; 4) reports explaining and/or refining mechanisms of adverse interactions; and 5) cautions and important associated phenomenon of either a cardiac or a psychotropic drug, e.g., valproic acid and cases of life-threatening pancreatitis. Methods of publicizing the new knowledge of cardiac drug-psychotropic drug interactions, e.g., the Internet and web sites are described.

Triggering of cardiac events by sexual activity: findings from a case-crossover analysis

Although anecdotal reports have suggested that sexual activity increases the risk of acute myocardial infarction (MI), controlled studies to evaluate the magnitude of this risk have only recently been conducted. Using an epidemiologic technique called the case-crossover method, the Myocardial Infarction Onset Study (MIOS) has provided quantitative data on sexual activity as a trigger of MI onset. Sexual activity was found to double the relative risk of acute MI in healthy individuals and patients with a prior history of angina or MI. However, the absolute risk of sexually triggered MI remains extremely low, because the baseline risk of MI is low for most individuals and the increased risk due to sexual activity is transient. Regular exercise also was found to reduce the risk of MI by sexual activity. Given that >12 million people in the United States have coronary artery disease, these findings should be more widely disseminated to reassure patients that, in most cases, sexual activity carries little risk of causing a cardiac event. In the future, advances in research on the triggering of MI are likely to yield new approaches to the prevention of cardiovascular events through prospective identification of the vulnerable plaques that lead to coronary thrombosis, and prophylactic measures to sever the link between triggers and their potentially disastrous consequences.