Cardiovascular disease
Hypertension, coronary heart disease and ED frequently coexist.
Around 4 0% or more of ED patients may have some type of cardiovascular disease. Apart from representing a potential causative factor, the presence of underlying cardio’ vascular disease should be taken into consideration in patient management [10].
Hypertension: There is a strong association between hyperteu’ sion and ED. Around 17% of men with mitreated hypertension and 2 4% of men with treated hypertension have ED. It is not only antihypertensive therapy that causes ED, but hypertension itself. There is little evidence that treating hypertension will improve erectile function, although theoretically, the vascular remodeling and improvements in smooth muscle function might enhance erectile response. Hypertension kills people, through stroke, heart failure, and coronary heart disease. The development of ED can be an obstacle to patient compliance with antihypertensive therapy. Treating ED should not compromise achieving good blood pressure control using contemporary treatment guidelines [1,2]. Most men with welLcontroUed hypertension can be safely and effectively treated for ED; uncontrolled hypertension should be brought under control before ED therapy is initiated [18]. Men on such treatment should be routinely asked about their sexual and erectile function, regardless of age. There is no good evidence that changing antihypertensive agents improves erec’ tile function. Unless there is a strong temporal relationship between the introduction of a new drug and the onset of ED, it is unlikely that withdrawing a drug will be of benefit. There are theoretical grounds for suggesting that alphablockers, such as doxazosin, are less likely to cause ED than other agents. However, there is a potential interaction between alphablockers and PDE5 inhibitors that may result in significant hypotension in some patients. Caution should be exercised before co-prescribing these drugs, making reference to manufacturers’ recom’ mendations. Angiotensinconverting enzyme (ACE) inhibitors, angiotensin II (ATII) type I receptor blockers, and calcium channel blockers seem to have a fairly neutral effect on erections.
Modern beta-blockers, particidarly atenolol, are often blamed for causing ED, although the evidence for this is relatively poor. Propranolol and the older, centrally acting antihypertensives (e.g. clonidine) are more likely to cause ED. The evidence for thiazide diuretics causing ED is mixed but several long-term studies show a negative impact on erectile function.
Coronary heart disease: Coronary heart disease is associated with many of the same risk factors as ED, including dyslipidemia, hypertension, diabetes, smoking, and sedentary lifestyle.
Arterial disease in the heart is just one site in a generalized arteriopathy, which is likely to affect the ileal, pelvic, pudendal. and penile arteries, too. Urologists have been known to refer to ED as ‘atherosclerosis of the penis’ .
Research has shown that 4 4% of men who have had a myocardial infarction also have ED. This is probably due to more gener alized vascular disease, rather than impaired cardiac function. Psychosexual issues may also affect erection in men with coronary heart disease. They, and their partners, may be afraid that the exertion and excitement of intercourse could precipitate a further coronary episode.
The vast majority of men with coronary heart disease can safely resume sexual activity and use ED therapies. Education and appropriate counseling about sex should be given to all men with coronary heart disease so that the majority can continue to enjoy this important aspect of their relationship.
Men with unstable heart disease, a history of recent myocardial infarction, poorly compensated heart failure or unstable dysrhythmia are exceptions. Men taking nitric oxide-donor drugs must not take PDE5 inhibitors because of associated hypotension. ACE inhibitors, modern beta-blockers and calcium channel blockers, in normal doses, are unlikely to be a major contributory factor to the development of ED. Much the same can be said of nitrates and nicorandil. However, their use will absolutely preclude the use of PDE5 inhibitors as an ED treatment option. Unlike ACE inhibitors and beta-blockers, they convey no prognostic benefit with regard to the development of further coronary episodes. As such, one can consider their replacement with other anti-anginal agents. Some men may have been given a supply of glyceryl trinitrate
tablets or spray upon their discharge from hospital foUowing a coronary event, even though they do not have angina. They will often have been told to carry it with them at all times
and will have dutifully obeyed these instructions for many years, regularly refilling their prescription from their family physician, even though they never use the drug. Men who never use this medication should be reviewed by their cardiologist or family physician and, if appropriate, be advised that they do not need to carry nitrate therapy, thus enabling them to have PDE5 inhibitors as an ED treatment option.
Tags: Antihypertensive Agents, Blood Pressure Control, Causative Factor, Coronary Heart Disease, Doxazosin, Ed Patients, Good Blood, Heart Disease, Heart Failure, Hypertension, Hypotension, Patient Compliance, Patient Management, Pde5 Inhibitors, Smooth Muscle Function, Strong Association, Temporal Relationship, Theoretical Grounds, Uncontrolled Hypertension, Vascular Disease