ReviewSexual Dysfunction and Cardiac Risk (the Second Princeton Consensus Conference)
Section snippets
Management Recommendations
Consensus statements were formulated by the panel after the presentation of each topic by a senior investigator, discussion of the research findings, and review of previous recommendations. The final preparation and modifications of the consensus study were made by electronic communication. The final recommendations were approved by a unanimous consensus of the panel. The participants reaffirmed the value and applicability of the original guidelines and the Princeton stratification algorithm.
Asymptomatic, <3 cardiovascular risk factors
Patients with <3 major risk factors for cardiovascular disease (excluding gender) are generally at low risk for significant cardiac complications from sexual activity or the treatment of sexual dysfunction (Table 1). These patients are usually good candidates for pharmacologic and nonpharmacologic treatments for ED.
Controlled hypertension
Patients whose blood pressure is well controlled with ≥1 antihypertensive medication may safely receive approved medical therapies for sexual dysfunction. However, β blockers and
High-Risk Patients
The high-risk category consists of patients whose cardiac conditions are sufficiently severe and/or unstable that sexual activity may pose a significant risk. Most such patients are moderately to severely symptomatic. High-risk patients should be referred for cardiologic assessment and treatment. Sexual activity should be deferred until a patient’s cardiac condition has been stabilized by treatment or a decision has been made by a cardiologist and/or internist that sexual activity may be safely
Intermediate- or Indeterminate-Risk Patients
Patients whose cardiac conditions are uncertain, as well as those with multiple risk factors, require further testing or evaluation before resuming sexual activity. On the basis of results of this evaluation, these patients may be subsequently classified as either at high or low risk from sexual activity. Cardiology consultation may be of value in some cases to assist primary physicians in assessing the risk of sexual activity for patients as follows.
Final Algorithm for Risk Stratification and Patient Management
Figure 1 shows a simplified algorithm for cardiovascular risk stratification and patient management. This algorithm views the assessment and management of patients with possible ED as a 3-step process.
Overall safety
Controlled and postmarketing studies of the US Food and Drug Administration-approved PDE-5 inhibitors (sildenafil, vardenafil, tadalafil) demonstrated no increase in MI or death rates in men who received these agents as part of either double-blind, placebo-controlled trials or open-label studies, compared with expected rates.14, 15, 16, 17 Patients with known coronary artery disease or heart failure receiving PDE-5 inhibitors did not exhibit worsening ischemia, coronary vasoconstriction, or
Emergency Department Considerations: Management of Cardiovascular Symptoms or Priapism in PDE-5-Inhibited Patients
Specific recommendations for patients presenting to the emergency department with acute cardiovascular symptoms or priapism were considered. Contacts between emergency department staff members and patients presenting with cardiovascular symptoms afford 2 important opportunities for the management of patients with ED: (1) to avoid potentially lethal co-administration of PDE-5 inhibitors and nitrates and (2) to identify patients at high risk for acute MI and death. Accordingly, emergency
Future Applications: Role of PDE-5 Inhibition in Cardiovascular Disease
PDE-5 inhibitors are currently approved by the Food and Drug Administration for treating ED. However, this class of drugs may have potential benefits for endothelial or cardiac function. Sildenafil was shown to decrease pulmonary artery pressures, improve cardiac output, and reduce symptoms in patients with pulmonary hypertension.34, 35 It has been approved by the FDA for the treatment of pulmonary arterial hypertension (WHO Group I) to improve exercise ability. In preliminary studies,
Non-PDE-5 Inhibitor ED Therapies and the Cardiovascular System
Other pharmacologic agents besides PDE-5 inhibitors are used to treat ED and may affect the cardiovascular system. Yohimbine, an α-2 receptor blocker, has been advocated for more than a century as a treatment for ED.41 Results to date with yohimbine have been inconsistent, however, and adverse cardiovascular events have been observed in some studies. l-Arginine is the precursor of nitric oxide. It has been evaluated in men with minimal or mild ED, for which a benefit over placebo was recorded
Hypogonadism and Testosterone Therapy
The role of testosterone therapy for hypogonadism is expanding, in part because of increasing awareness of ED and recognition of hypogonadism as a co-morbid condition associated with type 2 diabetes, the metabolic syndrome, and other chronic systemic illnesses.45 The use of testosterone as an adjunctive therapy to PDE-5 inhibitors for the treatment of ED and hypogonadism has resulted in successful outcomes in patients in whom PDE-5 inhibitor therapy alone has failed.46 Published research
Primary Care Management, Disease Prevention, and Lifestyle Modification: Toward a Patient-Centered Approach
For generalists and specialists alike, the management of patients with ED and concomitant cardiovascular disease or risk factors presents unique challenges and opportunities. Current guidelines emphasize the need for a complete medical history and physical examination, in addition to laboratory testing, as needed49 (Figure 2). Co-morbid cardiovascular diseases or significant risk factors, in particular, including hypertension, diabetes, and dyslipidemia, are key areas to investigate in the
References (53)
- et al.
Management of sexual dysfunction in patients with cardiovascular diseasethe Princeton Consensus Panel
Am J Cardiol
(2000) - et al.
Impaired brachial artery endothelium-dependent and -independent vasodilation in men with erectile dysfunction and no other clinical cardiovascular disease
J Am Coll Cardiol
(2004) - et al.
Erectile dysfunction and coronary risk factorsprospective results from the Massachusetts male aging study
Prev Med
(2000) - et al.
Heart disease risk factors predict erectile dysfunction 25 years later. The Rancho Bernardo Study
J Am Coll Cardiol
(2004) - et al.
Comparison of reported and expected deaths in sildenafil (Viagra) users
Am J Cardiol
(2002) - et al.
Evaluation of vardenafil and sildenafil on cardiac repolarization
Am J Cardiol
(2004) - et al.
ACC/AHA expert consensus document use of sildenafil (Viagra) in patients with cardiovascular disease
J Am Coll Cardiol
(1999) - et al.
Sildenafil citrate potentiates the hypotensive effects of nitric oxide donor drugs in male patients with stable angina
J Am Coll Cardiol
(2000) - et al.
Time course of the interaction between tadalafil and nitrates
J Am Coll Cardiol
(2003) - et al.
Interaction between the phosphodiesterase 5 inhibitor, tadalafil, and the two alpha blockersdoxazosin, and tamsulosin in healthy normotensive men
J Urol
(2004)
Effect of sildenafil in patients with erectile dysfunction taking antihypertensive therapy
Am J Hypertens
Safety of Viagra (sildenafil citrate) in men with erectile dysfunction and arterial hypertension who are taking multiple antihypertensive treatments
Am J Hypertens
Emergency evaluation and treatment of priapism
J Emerg Med
Clinical efficacy of sildenafil in primary pulmonary hypertension. Randomized, placebo-controlled, double-blind, crossover study
J Am Coll Cardiol
Acute type 5 phosphodiesterase inhibition with sildenafil enhances flow-mediated vasodilation in patients with chronic heart failure
J Am Coll Cardiol
Chronic treatment with tadalafil improves endothelial function in men with increased cardiovascular risk
Eur Urol
The effect of sildenafil on human vascular function, platelet activation, and myocardial ischemia
J Am Coll Cardiol
Randomized study of testosterone gel as adjunctive therapy to sildenafil in hypogonadal men with erectile dysfunction who do not respond to sildenafil alone
J Urol
Clinical evaluation and management strategy for sexual dysfunction in men and women
J Sexual Med
Impotence and its medical and psychosocial correlatesresults of the Massachusetts Male Aging Study
J Urol
Modifiable risk factors and erectile dysfunctioncan lifestyle changes modify risk?
Urology
Erectile dysfunction and the cardiovascular patientendothelial dysfunction is the common denominator
Heart
Sildenafil prevents endothelial dysfunction induced by ischemia and reperfusion via opening of adenosine triphosphate-sensitive potassium channels. A human in vivo study
Circulation
Sexual function in men older than 50 years of ageresults from the health professionals follow-up study
Ann Intern Med
Erectile dysfunction is a marker for cardiovascular complications and psychological functioning in men with hypertension
Int J Impot Res
Overview of phosphodiesterase 5 inhibition in erectile dysfunction
Am J Cardiol
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The Second Princeton Consensus Conference was supported by unrestricted educational grants from Pfizer Inc., New York, New York; Lilly/ICOS LLC, Bothell, Washington; Vivus, Palo Alto, California; Solvay, Marietta, Georgia; and Sanofi-Synthelabo, Bridgewater, New Jersey.