Heart Disease & Sexual Health

Erectile dysfunction (ED) has been a topic of great interest since the beginning of recorded history. References to erectile dysfunction appear in the Bible, characteristically in the form of punishments for transgressions against the Lord. In medieval times, erectile dysfunction was thought to be caused by the spell of witches.

Throughout history, cultures have sought remedies for ED. The ancient Egyptians and Greeks concocted a variety of potions hoping to cure the malady. Lacking modern science, all were doomed to failure. It was not until the past few decades when enhanced understanding of the physiology of male sexual function allowed development of breakthrough medicines to treat ED.

An all too common problem
Erectile dysfunction is very common, affecting to some degree more than half of all men age 40 years or older. The prevalence increases with age, with 70% of men older than 70 years experiencing ED. This condition is particularly important to our readers because ED is common in men with circulatory disorders and in those who take cardiovascular medications.

Risk factors the same for heart disease
Erectile dysfunction and cardiovascular disease share many of the same risk factors. Two key studies analyzing this topic include the Massachusetts Male Aging Study (MMAS) and the National Health and Nutrition Examination Survey (NHANES). The risk factors include:

Diabetes. This represents the most common risk factor, as more than half of all men with diabetes have ED. The onset of ED in patients with diabetes is associated with other complications of this disease involving the eye (retinopathy) and nervous system (sensory and autonomic neuropathy).

Hypertension. This is a controversial and complex association. Not all studies agree, but many support hypertension, particularly severe hypertension as a risk factor for ED. Complicating the analysis is that treatment with some blood pressure lowering agents clearly increases the likelihood of ED.

Smoking. The MMAS found that smoking nearly doubled the risk of moderate or complete ED compared with nonsmokers. It also markedly increases the risk of ED in men with heart disease and other cardiac risk factors.

Obesity and physical inactivity. Overweight men are more likely to have ED. The NHANES found that sedentary behavior was strongly correlated with ED. In the MMAS, men who were initially sedentary had lower rates of ED if they increased their level of activity.

ED and heart disease linked
Men who have coronary heart disease often have ED. One study of 300 men with angina and documented coronary disease found that 49% had ED. Conversely, men with ED have a high likelihood of coronary disease. A study analyzing nearly 13,000 men found that after adjustment for other risk factors, men with ED had double the risk of myocardial infarction compared with men without ED.

Sexual dysfunction may precede the onset of coronary symptoms. One analysis found that ED developed nearly three years prior to the onset of angina.

Why erections fail
When a man becomes sexually excited, nerve signals trigger release of a chemical that dilates the arteries supplying the penis. Blood flows into the penis, causing an erection. At the same time, veins draining the penis compress, maintaining the erection by preventing the outflow of blood. Disorders that either interfere with the nervous system or blood supply of the penis can cause ED.

Drugs to the rescue
Treatment of ED was revolutionized in 1998 with the release of sildenafil (Viagra). This drug was followed by vardenafil (Levitra) and tadalafil (Cialis). All work by inhibiting an enzyme (PDE5) that breaks down a chemical that dilates blood vessels (cGMP). With more cGMP, penile blood flow is enhanced and the erection is improved. These medications will not produce an erection in the absence of sexual arousal.

Viagra and Levitra are relatively short-acting drugs, beginning to work within 30-60 minutes with an effect lasting four hours. Cialis begins to work within 30 minutes, but has a much longer duration of action of 24-36 hours.

Is sex dangerous?
After proper medical evaluation, most stable cardiac patients can maintain their usual sex lives. This includes both men and women with chronic angina, after suffering a heart attack, or following cardiac surgery.

Many spouses worry about having sex with a partner who has a heart condition. This fear is largely unfounded. Sex is very unlikely to cause a heart attack and death during intercourse is extremely rare. Anger or emotional upset occurring as part of daily living is likely to pose a greater risk than sexual activity.

Sex is a relatively modest form of exercise. Healthy men having intercourse with their usual partners average a heart rate of 110-127 beats per minute. A traditional recommendation is that sexual activity requires about the same effort as walking up two flights of stairs.

The risk of coronary insufficiency during sex can be predicted by exercise testing. A 1995 study published in the American Journal of Cardiology found that all patients who had coronary insufficiency during sex also had abnormal stress tests. Conversely, a normal exercise test predicted adequate coronary blood flow during intercourse.

Guidelines exist to separate men into high, low and intermediate risk for sexual activity.

High risk. This includes men with a recent heart attack (< 2 weeks), decompensated congestive heart failure, uncontrolled angina, or severe valve disease such as aortic stenosis.

Low risk. Men with mild, stable angina, heart failure, or valve disease are considered low risk. Also included are those with successful angioplasty or bypass surgery, past heart attack (> 6-8 weeks), and other common conditions such as a trial fibrillation or controlled hypertension.

Intermediate risk. This includes all other men who require further evaluation to determine their risk. Exercise testing is usually needed to place them into another category.

Are ED drugs safe?
The safety of drugs for sexual dysfunction is an important question for cardiac patients because so many are affected with ED. After the launch of Viagra in 1998, reports of deaths associated with its use caused concern. Since then, research involving thousands of patients using all three currently available drugs of this class indicate that they are well-tolerated and safe for men with stable cardiovascular disease.

Side effects do occur with use of these drugs. The most common adverse reactions with all three are headache (7-22%), flushing (5-13%), and dyspepsia (1-11%). Vision disturbances, particularly changes in certain colors have been reported in some patients taking both Viagra and Levitra. The effect relates to the fact that these drugs also inhibit an enzyme in the eye. Cialis does not affect this enzyme. There have been sporadic reports of vision loss with these agents called nonarteritic anterior ischemic optic neuropathy (NAION). Whether the cause is truly due to use of ED drugs is not confirmed, but patients are now advised to stop the drug and contact their doctor for any sudden vision loss.

Some precautions necessary
All PDE5 inhibitors can modestly lower blood pressure. This effect is amplified by use of nitrates in any form with a potentially severe drop in blood pressure. Accordingly, short or long-acting nitrates (e.g., nitroglycerin, isosorbide) must not be combined with these drugs.

Many men with ED also have benign enlargement of the prostate gland or high blood pressure. Treatment can include alpha blockers such as doxazocin (Cardura) and terazocin (Hytrin), medications that can also potentiate the blood pressure lowering effect of ED drugs. This effect is not as pronounced as nitrates, but caution is advised when combining alpha blockers with PDE5 inhibitors.

More discussion wanted
Physicians lag behind patients in their inclination to discuss sexual activity and sexual function. One survey of coronary patients found that 81% of men and 64% of women desired a discussion of sexual function with their cardiologist. Only 3% of men and 18% of women indicated they received adequate information.

Cardiologists comment:
Medical options like Viagra, Levitra and Cialis have revolutionized treatment for erectile dysfunction. Patients are deluged with media exposure about treatments for sexual dysfunction, a topic once considered taboo. ED is frequently present in patients with cardiovascular disease and we routinely inquire about sexual function.

If you have ED, a medical evaluation is necessary. It is important to look for evidence of underlying cardiac disease and to treat risk factors. In some cases, a stress test is necessary to determine whether sexual activity is safe and before prescribing ED medications.

Never feel embarrassed to discuss erectile dysfunction with your doctor. Always tell your doctor whether you are taking ED medications and never obtain these medications over the Internet and without your doctor's prescription. Some individuals have mistakenly obtained ineffective, counterfeit drugs online. Remember that erectile dysfunction is just another medical condition that can now be treated with modern science. Perhaps the 18th-century German dramatist, Goethe said it best, "Gladly I think of the days when all my members were limber – all except one. Those days are certainly gone, now allmy members are stiff – all except one." —Franklin H. Zimmerman, MD

This article first appeared in the November/December 2007 issue of Heart & Health Reports. For a subscription, call 1-877-HEART-12.


Last Modified Date: April 01, 2013

All content on dLife.com is created and reviewed in compliance with our editorial policy.

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Jamis Roszler
Janis Roszler

Janis Roszler, MSFT, RD, CDE, LD/N is the American Association of Diabetes Educators' 2008-2009 Diabetes Educator of the Year.  She is a certified diabetes educator, marriage and family therapist, and registered dietitian. Her books include Sex and Diabetes (ADA) Diabetes on your OWN Terms (Marlowe & Co) and The Secrets of Living and Loving with Diabetes (Surrey books).

Donna Rice
Donna Rice

Donna Rice MBA,RN,CDE,FAADE is the 2007 Past President of the American Association of Diabetes Educators. She is a registered nurse, diabetes educator and has developed numerous educational programs on sexual health and wellness.  She is the co-author of  Sex and Diabetes (ADA) and Diabetes and Erectile Dysfunction - A Quick ‘n' Easy Handbook For the Diabetes Educator (Bella Vita).  Her newest publication is a children's book, The Magic is Me (Searchlight Press).

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