I have low diastolic blood pressure (~60‑70 mm Hg) and erectile dysfunction with anejaculation while taking apixaban (Eliquis); can I safely raise my diastolic pressure, use a vacuum erection device, is the anejaculation permanent, and are anti‑fibrotic or emerging cardiac‑fibrosis therapies beneficial?

Managing Low Diastolic Blood Pressure, Erectile Dysfunction, and Anejaculation on Anticoagulation

Your diastolic blood pressure in the 60s-70s range should not be artificially raised, as this level is generally safe and attempting to increase it could worsen your systolic pressure or compromise your overall cardiovascular management. 1, 2

Diastolic Blood Pressure Management

Do not attempt to raise your diastolic pressure. The evidence shows that diastolic pressures in the 60-70 mmHg range are acceptable in most patients, and the concern about the "J-curve" phenomenon (worse outcomes with very low diastolic pressure) remains controversial and inconsistent across studies. 1

Key Thresholds and Safety Data

• The critical threshold for concern is diastolic BP below 60 mmHg, particularly in patients over age 60 or with diabetes and documented coronary artery disease. 1
• Your current range of 60s-70s is above this threshold and does not require intervention. 2
• The American Heart Association states that "caution is advised in inducing falls of DBP below 60 mm Hg" in patients with occlusive coronary disease, but your pressures are not in this danger zone. 1
• Post-hoc analyses specifically identified DBP below 60 mmHg as high-risk, but DBP of 60-70 mmHg was not associated with the same level of concern. 2

Why Not to Raise Diastolic Pressure

• There is no safe or effective way to selectively raise diastolic pressure without also raising systolic pressure, which could worsen your overall cardiovascular risk. 1
• The vast majority of hypertensive individuals will not experience problems related to lowering of diastolic BP when standard medications are used. 1
• In heart failure patients with low baseline systolic BP (95-110 mmHg), certain medications like SGLT2 inhibitors and mineralocorticoid receptor antagonists actually caused mild BP increases, suggesting that improving cardiac function naturally optimizes blood pressure. 1

Vacuum Erection Devices on Anticoagulation

You can safely use a vacuum erection device while taking apixaban (Eliquis), but you must follow specific precautions to minimize bleeding risk.

Safety Evidence

• There is no absolute contraindication to vacuum erection devices in patients on anticoagulation in the cardiovascular literature. 1, 3, 4
• The primary concern is potential bruising or petechiae from excessive negative pressure, not life-threatening bleeding. 4

Safe Use Guidelines

• Use the lowest effective vacuum pressure and limit application time to 30 minutes maximum per session. 4
• Apply the constriction ring for no more than 30 minutes to prevent tissue ischemia. 4
• Monitor for excessive bruising, and if it occurs, reduce the vacuum pressure or frequency of use. 4
• Avoid use if you have any penile skin breakdown or active infection. 4

The advice you received about avoiding vacuum devices on Eliquis appears to be overly cautious and not supported by guideline-level evidence. 3, 4

Anejaculation Prognosis

Anejaculation is often permanent if caused by retroperitoneal surgery, radical prostatectomy, or autonomic neuropathy from diabetes, but the permanence depends entirely on the underlying cause.

Reversible Causes to Evaluate

• Medication-induced anejaculation (from alpha-blockers, antidepressants, antipsychotics) is reversible with drug discontinuation or substitution. 5, 6
• Psychological factors can be addressed with counseling or sex therapy. 4
• Testosterone deficiency, if present, may respond to replacement therapy. 6

Irreversible Causes

• Surgical damage to the sympathetic nerves (from retroperitoneal lymph node dissection, radical prostatectomy, or extensive pelvic surgery) typically causes permanent anejaculation. 4
• Advanced diabetic autonomic neuropathy causing anejaculation is generally irreversible. 6

You need to identify the specific cause of your anejaculation to determine if it is truly permanent. If you haven't had pelvic surgery or advanced diabetic neuropathy, there may be reversible factors. 5, 6

Anti-Fibrotic Agents and Cardiac Fibrosis

Anti-fibrotic agents are not currently recommended for erectile dysfunction or anejaculation, as these conditions are not primarily fibrotic processes.

Current Evidence on Cardiac Fibrosis Therapies

• Mineralocorticoid receptor antagonists (spironolactone, eplerenone) have anti-fibrotic effects on the myocardium and may improve erectile function by reducing vascular inflammation and improving endothelial function. 1, 6
• SGLT2 inhibitors have shown beneficial effects on cardiac remodeling and may improve erectile function indirectly through metabolic and vascular benefits. 1
• Renin-angiotensin-aldosterone system inhibitors (ACE inhibitors, ARBs) have the best profile among cardiovascular drugs for preserving or improving erectile function. 5, 6

Penile Fibrosis Considerations

• If you have Peyronie's disease or penile fibrosis from other causes, there are no FDA-approved anti-fibrotic agents specifically for this indication. 4
• Collagenase injections are approved for Peyronie's disease but do not address erectile dysfunction or anejaculation. 4

Emerging Research and Hope

There are several promising areas of research that may offer future options:

Phosphodiesterase-5 Inhibitors (PDE5i)

• Sildenafil, tadalafil, and vardenafil are safe and effective in patients with cardiovascular disease, including those on most cardiovascular medications. 3, 4, 6
• The only absolute contraindication is concurrent use with nitrates (within 24 hours for sildenafil/vardenafil, 48 hours for tadalafil). 1, 3, 4
• PDE5 inhibitors are safe with apixaban and do not increase bleeding risk. 3, 4
• Success rates for restoring erectile function reach up to 80% depending on etiology. 4
• These drugs cause only mild reductions in systolic and diastolic BP (typically 5-8/3-5 mmHg), which is well-tolerated in patients with your BP profile. 3

If you are not on nitrates, PDE5 inhibitors represent your best current option for erectile dysfunction. 3, 4, 6

Cardiovascular Medication Optimization

• Beta-blockers and thiazide diuretics have the worst profiles for erectile dysfunction. 5, 6
• Nebivolol (a selective beta-blocker) and RAAS inhibitors have the best profiles and may actually improve erectile function. 6
• Review your current cardiovascular medications with your cardiologist to determine if substitutions could improve sexual function without compromising cardiac outcomes. 5, 6

Novel Therapies Under Investigation

• Low-intensity shockwave therapy for erectile dysfunction shows promise in early trials but lacks definitive outcome data. 6
• Stem cell therapies are in early research phases with no clinical recommendations yet. 1
• Gene therapy approaches remain experimental. 1

Critical Pitfalls to Avoid

• Do not stop or reduce cardiovascular medications without physician guidance, as this increases mortality risk far more than sexual dysfunction impacts quality of life. 1
• Do not use PDE5 inhibitors if you are taking nitrates (nitroglycerin, isosorbide mononitrate, isosorbide dinitrate), as this combination can cause life-threatening hypotension. 1, 3
• Do not assume anejaculation is permanent without identifying the underlying cause through proper evaluation. 5, 6
• Do not focus exclusively on raising diastolic pressure, as there is no evidence this improves outcomes and it may worsen systolic hypertension. 1, 2

Practical Action Plan

1. Discuss PDE5 inhibitors with your physician if you are not on nitrates—this is your most evidence-based option for erectile dysfunction. 3, 4, 6
2. Request a medication review to identify any drugs that may be worsening erectile function (particularly beta-blockers other than nebivolol, thiazide diuretics, or alpha-blockers). 5, 6
3. Obtain proper evaluation for anejaculation including assessment for reversible causes (medications, testosterone deficiency, psychological factors). 5, 6
4. Consider vacuum erection device use with appropriate precautions despite anticoagulation. 4
5. Accept your current diastolic BP range as safe and do not pursue interventions to raise it. 1, 2