Issues and recommendations for treating erectile dysfunction in men with ischemic heart disease

Erectile dysfunction is a common disorder, affecting up to 30 million men. Because of common risk factors and effects of medication, erectile dysfunction often coexists with cardiovascular disease. The marketing of sildenafil for treatment of erectile dysfunction, the frequent coexistence of coronary artery disease and erectile dysfunction, and concerns surrounding the safety of sildenafil in cardiovascular patients-evoked by recent reports of serious adverse cardiovascular events temporally associated with its use-have renewed interest in understanding the cardiovascular effects of sildenafil and the physiologic effects of sexual activity. Additional research has shown sildenafil to be safe and effective. Specifically, sildenafil induces mild, transient, well tolerated vasodilation similar to that produced by nitrate therapy, without adversely affecting systemic, pulmonary, or coronary hemodynamics in either the general population or patients with stable coronary artery disease who are not treated with nitrates. The authors recently demonstrated that in patients with severe coronary artery disease, oral sildenafil had no adverse cardiovascular effects and a slight beneficial effect on coronary blood flow. However, a detrimental synergistic interaction between sildenafil and nitrates and an additive interaction between sildenafil and amlodipine have been noted. Nitrate therapy is therefore an absolute contraindication to sildenafil use and caution is necessary when sildenafil is prescribed with other antihypertensive medications. Initial studies by Masters and Johnson involving healthy subjects revealed heart rates approaching 170 beats per minute and respiratory rates exceeding 60 breaths per minute during coitus and led to the perception that coitus, especially at orgasm, was associated with nearly maximal or supermaximal cardiac workload. Subsequent studies have demonstrated significantly lower heart rates, blood pressures, and myocardial oxygen demands with sexual activity. In fact, the heart rates observed with sexual activity were often exceeded by rates measured during activities of daily living. On the basis of current understanding of the cardiovascular effects of sildenafil and of sexual activity, the American College of Cardiology/American Heart Association and the Princeton Consensus Panel have established guidelines for the use of sildenafil in the general population and in patients with cardiac disease. These guidelines advocate management strategies that accord with cardiac risk stratification and include exercise treadmill stress testing. With this approach, sildenafil use can be safe and effective and provide maximal benefit and minimal harm to the general population and to patients with cardiovascular disease.