How to manage erectile dysfunction in patients taking cardiac medications?

From the Guidelines

Erectile dysfunction in patients taking cardiac medications can be effectively managed by initiating therapy with a PDE-5 inhibitor, such as sildenafil, tadalafil, or vardenafil, while considering the individual's cardiovascular risk factors and potential interactions with other medications 1. When managing ED in patients with cardiac medications, it is essential to consider the potential risks and benefits of different treatment approaches. The American College of Physicians recommends that clinicians initiate therapy with a PDE-5 inhibitor in men who seek treatment for ED and who do not have a contraindication to PDE-5 inhibitor use, such as nitrate therapy 1.

Key Considerations

• PDE-5 inhibitors are generally safe with most cardiac medications, but timing is crucial - take them 1-2 hours before sexual activity.
• Alternative ED treatments, such as vacuum erection devices, penile injections (alprostadil), or penile implants, may be considered if medication approaches are not suitable.
• Lifestyle modifications, including regular exercise, weight management, smoking cessation, limiting alcohol, and managing stress, can also help improve both cardiac health and ED.

Cardiovascular Risk Assessment

The Princeton Consensus Panel recommends assigning patients to one of three risk levels (high, intermediate, and low) based on their cardiovascular risk factors 1.

• High-risk patients should not receive treatment for sexual dysfunction until their cardiac condition has stabilized.
• Low-risk patients may be considered for all first-line therapies.
• Patients whose risk is indeterminate should undergo further evaluation by a cardiologist before receiving therapies for sexual dysfunction.

Treatment Approach

The choice of a specific PDE-5 inhibitor should be based on the individual preferences of men with erectile dysfunction, including ease of use, cost of medication, and adverse effects profile 1.

• Sildenafil (Viagra, 25-100mg), tadalafil (Cialis, 5-20mg), or vardenafil (Levitra, 5-20mg) are commonly used PDE-5 inhibitors.
• Higher doses of PDE-5 inhibitors may be associated with a greater risk of adverse effects, but may also provide improved efficacy in some patients 1.

From the FDA Drug Label

Physicians should consider the cardiovascular status of their patients, since there is a degree of cardiac risk associated with sexual activity. In men for whom sexual activity is not recommended because of their underlying cardiovascular status, any treatment for erectile dysfunction, including tadalafil or vardenafil, should not be used. Patients with left ventricular outflow obstruction, (e.g., aortic stenosis and idiopathic hypertrophic subaortic stenosis) can be sensitive to the action of vasodilators, including PDE5 inhibitors The following groups of patients with cardiovascular disease were not included in clinical safety and efficacy trials for tadalafil or vardenafil, and therefore until further information is available, these medications are not recommended for the following groups of patients:

• myocardial infarction within the last 90 days
• unstable angina or angina occurring during sexual intercourse
• New York Heart Association Class 2 or greater heart failure in the last 6 months
• uncontrolled arrhythmias, hypotension (less than 90/50 mm Hg), or uncontrolled hypertension
• stroke within the last 6 months

Management of Erectile Dysfunction and Cardiac Meds: To manage erectile dysfunction in patients taking cardiac medications, physicians should carefully consider the patient's cardiovascular status before prescribing any treatment for erectile dysfunction.

• Assess the patient's cardiac risk associated with sexual activity.
• Evaluate the patient's underlying cardiovascular disease and consider the potential interactions between erectile dysfunction medications (e.g., tadalafil or vardenafil) and cardiac medications.
• Avoid using erectile dysfunction medications in patients for whom sexual activity is not recommended due to their underlying cardiovascular status.
• Monitor patients closely for potential adverse effects, such as hypotension or angina, when using erectile dysfunction medications with cardiac medications.
• Adjust the treatment plan as needed to minimize the risk of adverse interactions between erectile dysfunction medications and cardiac medications. 2 3 3

From the Research

Management of Erectile Dysfunction with Cardiac Medications

• Erectile dysfunction (ED) is common in patients with cardiovascular disease and shares the same risk factors, such as smoking, hypertension, hyperlipidaemia, and diabetes mellitus 4.
• The treatment of ED in patients with cardiovascular disease has been transformed by the introduction of oral phosphodiesterase type 5 inhibitors, with success in restoring erectile function possible in up to 80% of patients 4.
• Phosphodiesterase type 5 inhibitors, such as sildenafil, tadalafil, and vardenafil, are recognized as efficacious and well-tolerated, and are the first-line treatment for ED 5.

Considerations for Patients with Cardiovascular Disease

• Patients with preexisting cardiovascular disease and ED should be stratified according to their cardiovascular risk, and sexual activity is safe in patients at low risk of cardiovascular disease 6.
• Men at high risk of cardiovascular disease should be reassessed and the cardiac condition should be stabilized before they can have sexual attempts 6.
• The use of phosphodiesterase type 5 inhibitors in patients with cardiovascular disease requires caution, particularly with regards to interactions with nitrates and alpha-blockers 7.

Treatment Options

• Phosphodiesterase type 5 inhibitors, such as tadalafil, vardenafil, and sildenafil, are effective and safe for the treatment of ED, with tadalafil being the preferred drug by patients and physicians due to its pharmacological profile 8.
• Daily treatment with phosphodiesterase type 5 inhibitors is another option in men with ED and documented vascular or prostate disease 8.
• Lifestyle changes, administration of phosphodiesterase type-5 inhibitors, and testosterone supplementation may improve sexual function and reduce the risk of experiencing cardiovascular disease during follow-up 6.