A case of erectile dysfunction and risk factors for coronary artery disease

Abstract

The hypothetical case of a man with erectile dysfunction and multiple cardiovascular risk factors is presented to illustrate the use of the second Princeton Consensus Conference Guidelines. Methods to optimize efficacy of the phosphodiesterase inhibitors are described. The overall cardiovascular safety of the phosphodiesterase inhibitors and their interaction with organic nitrates and alpha blockers are discussed. International Journal of Impotence Research (2005) 17, S7-S11. doi:10.1038/sj.ijir.3901423Keywords: erectile dysfunction; cardiovascular risk factors; hypertension; angina pectoris; Princeton Consensus Conference Guidelines; phosphodiesterase inhibitors; sildenafil; vardenafil; tadalafil The caseA hypothetical 58-y-old male presents to his physician with the complaint of erectile dysfunction (ED) for about 1 y. He reports that sexual desire is present but that he has a lack of ability to achieve and maintain erection. He notes that he has avoided physical affection with his wife in order to avoid the embarrassment of 'not being able to perform.' He often falls asleep early so that he may avoid initiation of sexual contact. The man is overweight and has a 5-y history of hypertension, which is being treated with a thiazide diuretic and calcium channel blocker. He has a history of smoking one pack of cigarettes every few days for at least 30 y. He does not exercise and occasionally notes cramps in his legs when he walks more than four blocks.Had this patient presented with the same story 20 or 30 y ago to a physician, he might have been told that the ED was psychological and that probably very little could have been done to help him.Today this patient's history is rather typical. He presents with ED and has multiple risk factors for atherosclerotic vascular disease-age, gender, smoking, hypertension, and sedentary lifestyle. [1][2][3] It is now well recognized that cardiovascular risk factors, the same factors associated with the development of endothelial dysfunction, 4-6 are also risk factors for ED. These include treatable risk factors such as smoking, hypertension, lipid abnormalities, diabetes, and sedentary lifestyle. [1][2][3][4][5][6] In addition, this patient is taking a thiazide diuretic for hypertension. Several medicines have been associated with ED, including certain antihypertensives. Thiazide diuretics and beta blockers are the two antihypertensive agents most likely to cause ED. 7,8 Calcium channel blockers and angiotensin converting enzyme inhibitors are less likely to have this effect and there are even a few small reports suggesting that angiotensin receptor blockers are protective against ED. 9 Physical examination of the patient reveals a moderately obese male in no acute distress. Eye examination shows mild arteriolar narrowing. His heart rate is 80 beats per minute and blood pressure is 138/86 mmHg; hence although he has been on antihypertensive medicines his blood pressure is in the prehypertension level. Lungs reveal scattered rhonci and wheezes consistent with chronic obstructive...