How to manage erectile dysfunction in a middle-aged to older adult male with 3-vessel disease (three-vessel coronary artery disease) who has refused coronary artery bypass grafting (CABG)?

Managing Erectile Dysfunction in a Patient with 3-Vessel Disease Who Refused CABG

Start with phosphodiesterase type 5 (PDE5) inhibitors as first-line therapy after confirming the patient is not on nitrate therapy and has stable cardiovascular status, while simultaneously implementing aggressive lifestyle modifications and optimizing medical management of coronary disease. 1, 2

Cardiovascular Risk Assessment and Safety Considerations

Before initiating any ED treatment, perform cardiovascular risk stratification:

• Assess exercise capacity: Sexual activity is safe for patients who can exercise at 5 METs without angina, excessive dyspnea, ischemic ST-segment changes, hypotension, or arrhythmia 1
• Evaluate cardiac symptoms: Patients with stable coronary disease who are asymptomatic or have no ischemia during stress testing are at low risk for sexual activity-triggered cardiovascular events 1
• Screen for absolute contraindications: Do not prescribe PDE5 inhibitors if the patient is taking nitrates (including long-acting nitrates), has unstable angina, uncontrolled hypertension, or recent MI/stroke within 90 days 1, 3

Critical Safety Warning

PDE5 inhibitors are absolutely contraindicated with concurrent nitrate use due to risk of severe hypotension and myocardial infarction. 1, 3 If the patient uses nitrates for angina, you must choose between continuing nitrates or treating ED—these cannot be combined. For patients on long-acting nitrates who want PDE5 inhibitors, discontinue nitrates and use alternative anti-anginal therapy only if clinically appropriate. 1

First-Line Pharmacological Treatment

PDE5 Inhibitors

Initiate oral PDE5 inhibitor therapy as first-line treatment:

• Tadalafil: Start 10 mg as needed (taken prior to sexual activity), may increase to 20 mg or decrease to 5 mg based on response 3
  • Alternative: Tadalafil 2.5-5 mg daily for continuous therapy 3
  • Advantage: Effective up to 36 hours after dosing 3
• Sildenafil: 50-100 mg as needed 2, 4
• Vardenafil or Avanafil: Alternative options with similar efficacy 2

Expected efficacy: 60-65% success rate in general population, though patients with cardiovascular disease may have slightly lower response rates 2, 5

Dosing Adjustments for Renal Impairment

Given the high likelihood of renal impairment in patients with 3-vessel disease:

• CrCl 30-50 mL/min: Start tadalafil 5 mg, maximum 10 mg once every 48 hours 3
• CrCl <30 mL/min or hemodialysis: Maximum tadalafil 5 mg once every 72 hours 3

Mandatory Lifestyle Modifications and Risk Factor Management

These interventions improve both erectile function AND reduce cardiovascular mortality—they are not optional:

• Smoking cessation: Reduces total mortality by 36% in coronary disease patients and improves endothelial function 1, 2
• Regular aerobic exercise: Decreases peak coital heart rate and reduces risk of sexual activity-triggered MI 1, 2
• Weight loss: Marked improvements in erectile function demonstrated in obese men with moderate ED 1
• Mediterranean diet: Emphasizing fruits, vegetables, whole grains, fish, and limiting red meat 2
• Moderate alcohol consumption: <14 units/week for women, <21 units/week for men; avoid binge drinking 1, 2
• Optimize glycemic control: If diabetic 2, 4
• Blood pressure control: Target <140/90 mmHg 2, 4
• Lipid management: High-intensity statin therapy with ≥50% LDL-C reduction 1

Optimizing Medical Therapy

Review and Adjust Cardiovascular Medications

Beta-blockers confer 3 times the risk of erectile dysfunction—consider switching to alternative agents if blood pressure and heart rate control permit: 1, 2

• Preferred alternatives: ACE inhibitors or ARBs (best profiles for erectile function) 2, 6
• Nebivolol: If beta-blocker necessary, has better erectile function profile than traditional beta-blockers 6
• Avoid or minimize: Thiazide diuretics (associated with ED) 2, 6

Testosterone Assessment and Replacement

Check morning total testosterone level in all patients, especially if PDE5 inhibitors fail: 2, 7

• Testosterone <230 ng/dL with symptoms: Initiate testosterone replacement therapy—improves sexual function and enhances PDE5 inhibitor response 2, 7
• Testosterone 230-350 ng/dL with symptoms: Consider testosterone replacement 2
• Testosterone >350 ng/dL: Replacement not indicated 2

Important: PDE5 inhibitors require adequate testosterone levels for full efficacy 2, 4

Second-Line Therapies (If PDE5 Inhibitors Fail)

Intracavernous Injection Therapy

Alprostadil 10-40 mcg intracavernous injection:

• Success rate: 73-76% achieve adequate erections 4
• Mean effective dose: 13.8-25.9 mcg 4
• Critical: Ensure 24/7 priapism treatment availability before initiating 7

Vacuum Constriction Devices

• Success rate: 69% in patients with vascular ED 4
• Non-invasive mechanical option 2

Intraurethral Alprostadil

• Alternative local therapy option 2

Psychosexual Counseling (Essential Adjunct)

Provide or refer for psychosexual therapy—this is not optional: 2, 7

• Success rates: 50-80% when combined with physical therapies 7
• Address anxiety, depression, performance concerns, and relationship issues 1, 7
• Partner involvement is essential for optimal outcomes 2, 7

Specific Counseling Points

• Reassure: Relative risk of cardiac event with sexual activity is low 1
• Symptom reporting: Report chest pain, shortness of breath, rapid/irregular heart rate, dizziness, or excessive fatigue 1
• Nitrate use: If prescribed nitrates, can take before sexual activity if chest pain occurs, but seek immediate medical attention for unrelieved chest pain 1
• Energy conservation: Use positions requiring less energy expenditure (e.g., patient in bottom or semi-reclining position) 1
• Timing: Be well-rested before sexual activity 1

Special Considerations for 3-Vessel Disease Without Revascularization

This patient has NO indication for dual antiplatelet therapy (DAPT) since they refused CABG and presumably did not undergo PCI: 1

• DAPT indicated only if percutaneous revascularization performed 1
• No evidence supports DAPT in stable CAD treated conservatively 1
• Continue single antiplatelet (aspirin) plus optimal medical therapy 1

Erectile dysfunction may be an early marker of progressive cardiovascular disease—use this as an opportunity to: 2, 5, 6

• Reassess need for revascularization (PCI may be option if CABG refused) 1
• Intensify cardiovascular risk factor modification 2, 5
• Screen for diabetes, hypertension, hyperlipidemia if not already done 2, 6

Common Pitfalls to Avoid

• Never combine PDE5 inhibitors with nitrates: Wait ≥24 hours after sildenafil/vardenafil or ≥48 hours after tadalafil before giving nitrates 1, 3
• Don't assume ED is purely psychological: Vascular ED is the most common etiology in coronary disease patients 2, 5
• Don't ignore testosterone: Check levels in all patients, especially non-responders to PDE5 inhibitors 2, 7
• Don't forget partner involvement: Treatment success significantly improved with partner participation 2, 7
• Don't overlook medication review: Beta-blockers and diuretics are major contributors to ED 2, 6

Surgical Options (Generally Not Applicable)

Penile prosthesis implantation is reserved for refractory ED after all other options exhausted 2—unlikely to be first consideration in this patient with significant cardiovascular disease.