OPTIMIZING THE MANAGEMENT OF ED

Managing Concomitant Cardiac

Disease and Erectile Dysfunction
Richard A. Stein, MD
Weill Cornell Medical Center, New York, NY and Brooklyn Hospital Center, Brooklyn, NY

Early studies of peak heart rates and blood pressure during coitus led physicians
to believe that sexual activity represents a significant risk to patients with
cardiovascular disease. Subsequent studies indicated, however, that the heart
rate during coitus was no higher than the rate during unaccustomed physical
exercise or associated with anger. The absolute risk of myocardial infarction
(MI) in a patient with a history of MI has been found to be 10 per million
per hour, and the doubling of this risk in the 2 hours following coitus has a
negligible impact on annual risk. Coronary artery disease (CAD) is a powerful
indicator of the presence of erectile dysfunction (ED), and the risk factors for
ED are similar to those for CAD. Studies of sildenafil citrate use in patients
with a history of cardiovascular disease have found sildenafil to be safe and
effective, except for an absolute contraindication in the concomitant use of
nitrates. Physicians should become familiar with the clinical guidelines for
classifying ED patients with a history of cardiovascular disease as high risk,
intermediate or indeterminate risk, and low risk. The guidelines permit physicians
MIlow risk while deferring the resumption of sexual activity among higher
risk patients pending further evaluation. [Rev Urol. 2002;4(suppl 3):S39S47]

2002 MedReviews, LLC

Key words: Erectile dysfunction Cardiovascular disease Coitus Myocardial infarction

Sildenafil citrate

T
he physician caring for a patient with erectile dysfunction (ED) is often placed in
the position of dealing with this clinical presentation in the context of cardio-
vascular disease. The association of ED and cardiovascular disease is greater
than would be expected on the basis of age and gender alone. In the Massachusetts
Male Aging Study,1 ED was associated with increasing age and several athero-
sclerotic vascular disease risk factors. An elevated low-density lipoprotein (LDL)

VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY S39

Managing Cardiac Disease and ED continued
cholesterol or low high-density
lipoprotein (HDL) cholesterol, diabetes
mellitus, hypertension, or smoking at
entry into the prospective cohort
study was associated with a nearly
4-fold increase in the risk of devel-
oping ED for a single factor, and a
greater likelihood of developing ED
if multiple factors were present.
Essentially, the risk factors for ED are
the same as the risk factors for coro-
nary artery disease (CAD).
Essentially, the risk factors for ED are the same as the risk factors for
coronary artery disease.
Given these findings, it is not sur-
prising that CAD is a powerful indica-
tor of the presence of or development
of ED, and the greater the extent of
the heart disease the greater is the
likelihood of ED. Dhabuwala and
colleagues2 noted that 42% of their
male patients who had a myocardial
infarction (MI) reported ED. Greenstein
and associates3 reported, in a study
of 40 men with CAD, that patients
with multi-vessel CAD were more
likely to experience ED than were men
with single-vessel disease. An addi-
tional consideration is the presence
of occult (not known to the patient
or the physician) CAD. Occult CAD
increases with age, and studies of CAD
by nuclear imaging have suggested
that in patients at age 70 more than
33% of CAD is occult. In this context,
the physician treating ED will confront
cardiovascular disease as a comor-
bidity" in a significant number of
patients and must appropriately
adapt the clinical evaluation to meet
the patient presentation.
Several documents, published in
1999, address aspects of the medical
management of EDin most cases
the prescribing of sildenafil citrate
in patients with known or suspected
cardiac disease. These include 1) the
S40 VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY
joint American College of Cardiology/
American Heart Associationspon-
sored expert panel consensus state-
ment regarding the use of sildenafil in
patients with cardiovascular disease4;
2) a statement on the use of silde-
nafil in the management of sexual
dysfunction in patients with cardio-
vascular disease presented under the
auspices of the Heart and Stroke
Foundation of Canada and the
Canadian Cardiovascular Society5;
and 3) the recommendations of the
Princeton Consensus Panel for the
management of sexual dysfunction
in patients with cardiovascular dis-
ease.6 The latter document was drafted
after the ACC/AHA consensus state-
ment and addresses, in a focused man-
ner, the evaluation of the ED patient
with known or possible cardiovascular
disease and the use of sildenafil.
The basis for the evaluation and
management of ED in the setting of
cardiovascular disease, which is the
focus of this review, is the knowledge
base regarding the cardiovascular
response to coitus, the risk of acute
cardiovascular events during or fol-
lowing sexual activity, and the interac-
tion of sildenafil, a phosphodiesterase
5 inhibitor, with this physiology and
pathophysiology.
The Cardiovascular Response to
Sexual Activity
The response of the cardiovascular
system to coitus and other sexual
activity has been the subject of a
number of studies in the recent past.
These studies have been conducted
against the backdrop of a popular
mythology" in the lay and health
care provider community concerning
the intensity of the physiologic
response to coitus and orgasm, and the
belief that sexual activity represents a
significant risk in patients with known
or occult CAD. In part, this perception
was fostered by the work of Bartlett,7
published in 1956, and Masters and
Johnson,8 published in 1961. They
were among the first to study heart
rate (HR) and blood pressure (BP) in
student couples engaging in coitus in
a private" laboratory room.
Early Studies of the Physiological
Response to Coitus
Bartlett studied three couples
engaged in coitus in an experimental
room with wires going through the
wall and the couples signaling the
stages of coitus, intromission, orgasm,
and withdrawal by hand-held buttons.
They noted that peak heart rates
occurred at orgasm and were a mean
of 170/min. A follow-up study was
performed with couples wearing
mouthpieces that permitted the col-
lection and analysis of expired air
during coitus. Respiratory rates and
tidal volumes were noted to increase
in all subjects (the highest respiratory
rate noted during orgasm was
60/min), and minute volumes were in
the range expected during moderate-
to-severe exertion.
Masters and Johnson measured
heart rates and blood pressure and
found that heart rates in males
ranged from 140/min to 180/min.
Blood pressure was measured
via a through-the-wall" sphygmo-
manometer tube, and mean values
for systolic BP increased by 80 mm
Hg and for diastolic BP by 50 mm Hg
during coitus. The potentially con-
founding impact of performance
anxiety, coitus among nonlong-
term sex partners, and having their
data watched" in the next room
during the coitus, was not fully
addressed, and these heart rates and
blood pressures became the working
numbers" for the next several years.
 Managing Cardiac Disease and ED

At-Home" Studies and "Real-
World" Data on the Cardiac
Response to Coitus
In 1970, Herman Hellerstein and
Ernst Friedman of the Cleveland
Clinic published their findings on
men who were enrolled in a cardiac
rehabilitation program and were
sexually active with their spouses.9
A total of 91 patients responded to
a questionnaire regarding sexual fre-
quency and symptoms, and 14 of these
subjects engaged in coitus at home
with their spouses (usual place, time,
partner, position, and foreplay) while
wearing 24 hour ambulatory EKG
recorders. Hellerstein and Friedman
noted significantly lower peak heart
ratesa mean of 117.4/min, with a
range of 90/min to 144/min at
orgasm in 14 subjectsthan were
reported by Bartlett and by Masters
and Johnson. The Hellerstein-
Friedman patients were older (mean
age, 47.5 years), and their cardiores-
piratory fitness, assessed by the
measurement of maximum oxygen
consumption during maximal exer-
ciseEKG testing, was similar to that
reported for ambulatory, middle-aged
normal subjects. Of interest is that the
24-hour ambulatory EKG recording
often noted heart rates that exceeded
those achieved at coitus when the
patient was engaged in occupational
or home recreational activities.
Hellerstein and Friedmans data is
important to our understanding of
the physiological response to coitus
in the usual" patient of interesta
middle-aged, normally active male
who engages in coitus with a long-
term, stable sex partner. Their finding
of a peak heart rateand by extrap-
olation, peak myocardial oxygen
requirement (estimated from changes
in the double product" of HR  BP
systolic)that was well below maxi-
mum values and was frequently
exceeded during daily activities,
placed the cardiac response to coitus
in the real-world" range. Their
measurement of minute oxygen con-
sumption at coital heart rates denotes
that coitus, in the usual manner in
middle-aged men, imposes only a
modest physiologic cost.
Stein10 studied coital heart rates
with ambulatory EKG recorders and
maximum oxygen consumption with
treadmill exerciseEKG testing in
postmyocardial infarction men, before
and after a 16-week bicycle ergometer
exercise training program. Peak coital
heart rates prior to exercise training
were a mean of 127/min (range,
120130/min). After the 16-week
exercise program, a training effect
was confirmed by an 11.5% increase
Hellerstein and Friedman noted significantly lower peak heart ratesa
mean of 117.4/min, with a range of 90/min to 144/min at orgasm in 14
subjectsthan were reported by Bartlett and by Masters and Johnson.
in mean peak minute oxygen con-
sumption. Peak coital heart rates fell
modestly but significantly compared
with the heart rates in a control
group. A training effect is expected
to reduce peak heart rates at given
exercise levels, consequent to an
enhanced oxygen-extraction capacity
of the trained muscles, with a conse-
quent reduction in the cardiac output
requirement. The reduction in coital
heart rates suggests that the heart
rate achieved during coitus is
responsive, at least in part, to the
same demands as endurance training
aerobic" activities.
The Impact of Coital Position
Further measurements of heart rates
at home were obtained, using ambu-
latory EKG recording, by Eleanor
Nemec and colleagues from the
University of Washington in
Seattle.11 They studied the impact of
coital position (man-on-top versus
woman-on-top) on peak achieved
coital heart rates in eight healthy
adult males. This was of interest
because clinicians were counseling
post-MI patients to use a woman-on-
top position on the assumption that
it would be associated with a lower
work level and a lower cardiac oxygen
requirement. Their subjects triggered
an automatic blood pressure machine
prior to coitus and at orgasm. The
subjects engaged in a total of 35
episodes of coitus with their spouses
in their own homes. Peak coital heart
rates (mean of 114/min with the man
on top and 117/min with the woman
on top) were not significantly
changed with the position, as was the
case with blood pressures (163/81 mm
Hg for the man on top, and 161/77
mm Hg for the woman on top) and
double product (HR  BP systolic).
The mean peak coital heart rates
were 61% of the age-predicted max-
imum heart rates for their subjects.
They noted that there is no physio-
logic rationale for counseling men to
alter a man-on-top coital position.
These studies, in contrast to the
early studies of Masters and Johnson
and Bartlett, measured the physio-
logical response to coitus in as usual
and noninstrumented a manner as
possible. The strength of such data is
the relevance of their findings to
real-life" coitus. The weakness of
at-home" measurements is that
blood pressure depends on automatic
cuff inflation, and sound discernment
and timing is left to the subjects;
thus, they may miss orgasm by
important seconds. In addition, the
measurement of peak oxygen con-
sumption, the most definitive method
of establishing coital workload and

VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY S41

Managing Cardiac Disease and ED continued
the percentage of peak exercise
capacity represented by coitus, cannot
be measured.
Laboratory Evaluation of the
Physiological Response to Coitus
Bohlen and colleagues12 used a highly
instrumented protocol in order to
study, in the most comprehensive
manner to date, the physiological
response to coitus in the laboratory
setting. Ten married couples participat-
ed in four sexual activities on different
days in a laboratory room," with
data-recording tubes and cables
passing through a wall. The men
were young (mean age, 33.2 years)
and very fit (VO2max was a mean of
In studies that compared heart rates during the day with those at peak
sexual activity, there were usually several instances of higher values during
daily activities than during peak coital activity.
54/mL/kg). Data collected included
HR, BP, and VO2. The four sexual
activities included coitus with the
husband on top, coitus with the wife
on top, noncoital stimulation of the
husband by the wife, and self-stimula-
tion by the husband alone. The stages
of sexual activity that were recorded
included 1) baseline resting, 2) fore-
play, 3) stimulation, and 4) orgasm.
Heart rates were noted to increase
at each stage of sexual activity, with
peak values occurring at orgasm.
Mean peak heart rates at orgasm with
self-stimulation and partner-stimula-
tion were 102/min, with wife-on-top
coitus were 120/min, and with hus-
band-on-top coitus were 127/min.
Double products (HR  BP systolic),
reflecting myocardial oxygen demand,
were approximately doubled with
self-stimulation and partner-stimu-
lation and were not significantly dif-
ferent from these values in either of
the coital positions. Minute oxygen
consumption obtained during the
S42 VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY
protocol included rest-baseline, fore-
play, and stimulation-orgasm.
The authors expressed VO2 in
terms of METs (1 MET = 3.5 mL
O2/kg/min). VO2 was only modestly
increased during self- and partner-
stimulation (1.7 and 1.8 METs), and
it was 2.5 METs for woman-on-top
and 3.3 METs for man-on-top coitus.
The latter value represents a VO2 of
11.7 mL/kg/min, which, interestingly,
is close to the same value obtained
by Hellerstein and Friedman.
The Bohlen data provide the most
comprehensive evaluation of the
physiological response to coitus avail-
able. The study is, however, limited in
its application to clinical situations in
that the subjects were exceptionally
fit young men, who were highly
instrumented (including facemasks to
collect expired air) during coitus that
was performed in a laboratory set-
ting." The lower heart rates they
noted most probably reflected the
high level of fitness of their subjects,
consistent with Steins data demon-
strating a reduced peak coital heart
rate after exercise training and con-
sequent enhancement in VO2max.
A concern regarding the relevance
of the above-noted blood pressure
data is that the time involved in
inflating and slowly deflating the
cuff to permit the identification of
clear sounds may miss a very brief
significant elevation in blood pressure.
This is suggested from data collected
by Stewart Mann and colleagues
from Harrow, England.13 They utilized
indwelling radial artery catheters to
record continuous blood pressure for
a 24-hour period in a significant
number of untreated hypertensive
patients. Eighteen of their subjects
engaged in coitus during the record-
ing period. Surprisingly high peak
coital blood pressures were recorded
(mean, 237/138 mm Hg). Their data
raises the possibility that normal
subjects or treated hypertensive
patients may also have very brief,
significant elevations in blood pres-
sure. The physiological significance
of such very brief elevation in blood
pressure would be minor. Of greater
concern is that this may create shear
forces across an atherosclerotic
plaque that could trigger" plaque
fracture or erosion and cause subse-
quent thrombus formation and
acute MI.
It is clear that multiple studies
addressing heart rates and blood
pressure during coitus and measuring
or estimating workload and minute
oxygen consumption have produced,
by and large, consistent data. Peak
coital heart rates were noted to be in
the 114/min to 130/min ranges, with
the higher values found in younger
subjects, and the percentage of the
age-predicted maximum was close to
60% in several studies. In studies
that compared heart rates during the
day with those at peak sexual activity,
there were usually several instances
of higher values during daily activities
than during peak coital activity. Blood
pressures rose approximately 40 mm
Hg in both home-ambulatory and
laboratory settings. The data present-
ed by Mann and colleagues from the
United Kingdom are a source of con-
cern and suggest that a very transient,
significant elevation (above 220 mm
Hg) in systolic BP may accompany
orgasm. Work loads measured in a
laboratory setting with on-line minute
oxygen consumption and those esti-
mated by measurements performed
during ergometer exercise to coital
heart rates are remarkably similar,
indicating a moderate 3-to-4 MET
work load.

Risk of Acute Cardiac Event
Related to Coitus
Of great concern to the patient and
the clinician is the risk that coitus
may trigger an acute cardiac event
(eg, MI, sudden death, or the onset of
unstable angina). The mechanism
whereby an event or exposure could
induce acute physiologic changes
that might lead to an acute MI has
become clear only in the last decade.
It is now understood that most acute
MIs are precipitated by hemodynamic
forces that cause a vulnerable ather-
osclerotic plaque (one with a large
cholesterol pool at the center, active
lipid-filled inflammatory cells just
below the surface, and impaired
endothelial cells at the surface) to
fracture at the edge or erode the sur-
face at the top of the plaque. The
resultant exposure of prothrombotic
substances in the plaque to platelets
and other thrombus-initiating materi-
al in the blood induces the formation
of a thrombus rich in platelets and
fibrin that can suddenly occlude the
coronary artery.
Data regarding the actual risk of
MI associated with coitus was, until
recently, very limited and was con-
founded by reporting bias. In 1993,
M. Ueno, a Japanese pathologist,
reported on 5559 cases of sudden
death.14 Thirty-four of the cases were
recorded as having occurred during
or immediately after coitus; of these,
18 were determined at the autopsy
and case evaluation to be cardiac in
origin. The relatively low incidence
of coitus reported as proximate to
sudden death was noted (0.06%), but
of particular interest was that 27 of
the 34 cases occurred with coitus
involving extramarital sex partners.
The interpretation of this data in the
United States was that extramarital
sex was associated with a greater
physiologic demand and greater risk
of a cardiac event than was sex with
a spouse. It seemed that we had
Managing Cardiac Disease and ED
finally arrived at a physiological and
medical basis for marital fidelity!
This concept was in line with the
cultural mythology, supported by the
reported deaths of prominent figures
and television dramas in which char-
acters had cardiac events during
extramarital coitus.
The most comprehensive analysis
to date of the risk of an acute MI
being triggered" by coitus is the
data from the Myocardial Infarction
Onset Study.15 A total of 1774 patients
were questioned, within 24 hours of
an acute MI, with respect to their
activities and possible triggering"
exposures in the several hours prior
Data regarding the actual risk of MI associated with coitus was, until
recently, very limited and was confounded by reporting bias.
to their MI. Additionally, they were
questioned with regard to their activ-
ities and exposures during the same
period of time 1 day prior to their
infarct (a noninfarct day) and the
frequency of these activities and
exposures throughout the previous
year. They found that only 27 (3%)
of the 858 (48%) MI patients who
were sexually active in the year prior
to the MI reported sexual activity in
the 2 hours prior to the infarction.
They concluded that the relative risk
of an MI occurring in the 2 hours
after sexual activity was 2.5 (95%
confidence interval, 1.7-3.7). Of inter-
est is that the relative risk for patients
with a prior history of an MI (2.9)
was not significantly different from
the risk for those with no cardiac
history (2.5).
The study also showed that regular
exercise had a significant protective
effect, and that exercise three times a
week eliminated the increase in risk
associated with coitus. When com-
pared to other triggering events, coitus
was found to be similar to anger in
VOL. 4 SUPPL. 3 2002
the relative risk of an MI. Exposure
to anger was, however, much more
frequent (daily) compared to the
reported coital frequency, which
averaged less than once a week.
Data from the Framingham Heart
Study16 showed that a 50-year-old
man who is healthy and exercises
regularly has an absolute risk of MI
of 1 chance in a million per hour.
When this is doubled to 2 in a million
per hour for the two hours following
coitus, and coitus occurs once a
week, it has a negligible impact on
annual risk (1.01% annual risk com-
pared to 1.00% annual risk!) Indeed,
the increase in risk attributed to
coitus was found to be far less than
that associated with anger and unac-
customed physical exercise, and dur-
ing the 2 to 4 hours after awakening
associated with diurnal variation.
Even in the patient who has a histo-
ry of MI, where the absolute risk of a
subsequent MI is 10 per million per
hour, the doubling of this risk in the
2 hours after coitus 50 times a year
has a negligible impact on annual
risk. Based on the data from this
study, physicians and patients can be
reassured that in most cases sexual
activity carries very little risk of pre-
cipitating a cardiac event.
Of additional concern is the issue
of coitus inducing symptomatic and
life-threatening cardiac arrhythmia
in the absence of atherosclerotic
plaque rupture, which results in a
thrombosis causing an MI or unstable
angina. The data on cardiac arrhyth-
mia associated with coitus is limited.
In 1979, Johnston and Fletcher pub-
lished their findings from ambulatory
EKG recordings during at-home,
usual-partner sexual activity. The
REVIEWS IN UROLOGY S43
Managing Cardiac Disease and ED continued

24 subjects studied included post-MI
patients and post-coronary artery
bypass graft (CABG) patients.17 The
peak heart rates during coitus in the
post-CABG patients were higher (90
to 118/min) than they were in the
post-MI patients (74 to 108/min). Of
interest is their finding that 12 of the
24 patients had arrhythmias associ-
ated with sexual activity; 5 of these
Stable angina patients usually have a functional reserve that exceeds the
demands of coitus.
patients developed arrhythmias only
during coitus, not during the rest of
the ambulatory EKG recording.
Drory and colleagues from Tel-
Hashomer, Israel, addressed this issue
in 88 male outpatients, ranging from
36 to 66 years of age, with stable
coronary artery disease.18 Ambulatory
EKG recordings included sexual
activity and a near-maximum exercise
test in all subjects. Arrhythmia was
found during intercourse in 56% of
the patients and during the exercise
examination in 38% of the patients.
During the exercise examination,
patients with arrhythmia showed an
89% increase in ectopic beats.
During intercourse, this occurred in
only 11% of the patients, and most
common arrhythmia in coitus was
distinct in nature from the ambulatory
EKG during other times. A complex
arrhythmia was detected during
coitus in 12% of the patients. The
authors concluded that in most
patients existing rhythm disturbances
were not exacerbated during coitus,
and most arrhythmias noted during
coitus were simple.
Cardiovascular Risk Associated
with the Use of Sildenafil
Phase 3, placebo-controlled and
post-marketing trials of sildenafil
have demonstrated improvement in
erectile function with a concomitant
enhancement in sexual performance
and satisfaction in a large percentage
of appropriately treated patients.
Sildenafil blocks the action of phos-
phodiesterase 5 in the smooth muscles
that surround the penile arterial circu-
lation. This results in a prolongation
and enhancement of cyclic GMP-
mediated arterial dilatation, corpus
cavernosum engorgement, and a
penile erection induced by penile-
arteryproduced nitric oxide.
Studies have resolved initial con-
cerns regarding the use of sildenafil
in patients who are taking multiple
antihypertensive medications and
have demonstrated no increase in
adverse clinical events among such
patients. Moreover, studies addressing
the use of sildenafil and coronary
artery blood flow in normal and dis-
eased coronary arteries have not
revealed physiological alterations
that would prompt clinical concerns.
With the exception of the absolute
contraindication to the concomitant
use of sildenafil and nitrates, sildenafil
has been found to be safe and effec-
tive. The concern, however, regarding
the risk associated with coitus, made
possible by the use of sildenafil, is
small but real in selected patients.

Main Points
Coronary artery disease (CAD) is a powerful indicator of the presence of erectile dysfunction (ED). The risk factors for ED are similar
to those for CAD.
The physician must become familiar with the risks involved in treating men with ED and cardiovascular disease and be knowledgeable
about the guidelines for safely undertaking sexual activity.
Early studies of peak heart rates and blood pressure during coitus led to the belief that sexual activity represents a significant
risk in patients with CAD. Subsequent studies indicated that the heart rate during coitus was no higher than the rate during unac-
customed physical exercise or bouts of anger.
The absolute risk of myocardial infarction (MI) in a patient who has a history of MI has been found to be 10 per million per hour.
The doubling of this risk in the 2 hours following coitus has a negligible impact on annual risk. Of greater concern is that very
brief, significant elevations in blood pressure might create shear forces that could trigger plaque fracture or erosion, leading to
thrombus formation.
Regular exercise has a significant protective effect and may prevent the increase in risk associated with coitus.
Studies of sildenafil citrate use in patients with a history of cardiovascular disease have found sildenafil to be safe and effective.
An absolute contraindication, however, is the concomitant use of nitrates.
Physicians should be aware of the clinical guidelines for managing ED patients with a history of cardiovascular disease. The
guidelines categorize patients as high risk, intermediate or indeterminate risk, and low risk. These guidelines permit the large portion
of the patient population that is at low risk to initiate ED therapy and specify parameters to deal with higher risk patients.

S44 VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY


Table 1
Clinical Management of Sexual Dysfunction in Patients
with Cardiovascular Disease: Stratification of Patients into
High, Low, and Intermediate Risk Categories
Risk Category
Low risk: sexual activity is
not significant cardiac risk;
sexual activity may be initiated
with need for additional cardiac
evaluation or studies
Intermediate or indeterminate
risk: cardiac condition is uncertain
or risk profile requires further test-
ing or evaluation before sexual
activity is resumed; based on
testing patient may be assigned
to low- or high-risk categories
High risk: cardiac condition is
severe or unstable and sexual
activity may constitute significant
risk; sexual activity should be
deferred and the patient referred
for further cardiologic evaluation
and treatment
CHD, coronary heart disease; LDL, low-density lipoprotein; HDL, high-density lipoprotein;
CABG, coronary artery bypass graft; MI, myocardial infarction; NYHA, New York Heart
Association.
Data from DeBusk et al.6
Clinical Management of ED
Patients with Comorbid
Cardiovascular Diseases
The data from the studies described
above define the myocardial workload
Managing Cardiac Disease and ED
Parameters
A. Asymptomatic patients with <3
CHD risk factors (increased LDL
cholesterol, reduced HDL cholesterol,
hypertension, smoking, diabetes
mellitus, positive family history),
not including male gender
B. Controlled hypertension
C. Mild stable angina, evaluated
and treated
D. Post successful CABG
E. Uncomplicated past MI
F. Mild valvular disease
G. Congestive heart failure (left
ventricular dysfunction) NYHA
Class I (symptoms of dyspnea
only on vigorous activity)
A. >3 CHD risk factors
B. Moderate stable angina
C. Recent MI (26weeks)
D. Congestive heart failure (NYHA II)
E. Noncardiac sequelae of atheroscle-
rotic disease (eg, stroke, peripheral
vascular disease).
A. Unstable or refractory angina
B. Uncontrolled hypertension
C. Congestive heart failure NYHA
Class III/IV
D. Recent MI (<2 weeks)
E. High-risk arrhythmias
F. Hypertrophic obstructive and
other cardiomyopathies
G. Moderate-to-severe valvular
heart disease
and the resultant myocardial oxygen
demand for coitus as moderate" in
intensity. In fact, this workload is
exceeded during activities of daily
living in many patients. Additionally,
VOL. 4 SUPPL. 3 2002
the risk of triggering an MI is real
but very small in the 2 hours after
coitus; the actual risk is less than
that associated with episodes of
anger or vigorous bouts of exercise
which, in most instances, occur far
more frequently then coitus does. It
is clear, however, that this risk is
increased in patients who are seden-
tary. The risk is also presumably of
greater total magnitude in patients
with unstable coronary presenta-
tions, reflecting most probably the
presence of an increased number of
vulnerable atherosclerotic plaques.
Stratification of ED Patients by
Cardiac Risk Category
The clinical guidelines for managing
cardiovascular risk and sexual activity,
derived from the recommendations
of the Princeton Consensus Panel,6
are shown in Table 1. The guidelines
classify patients with regard to car-
diovascular status into low risk,
intermediate risk, and high risk of
cardiac events resulting from sexual
activity. The guidelines were designed
to permit the large portion of the rel-
evant patient population that is at
low risk to initiate ED therapy without
unnecessary delay or expense and to
defer resumption of sexual activity
and treatment of ED in patients who
require definitive treatment or fur-
ther evaluation.
Management Considerations for
Classes of Low-Risk Patients
Some hypertensive medication
induces ED, most importantly, -
blockers and diuretics. Clinical
experience has shown that
decreasing the dose or changing or
discontinuing the -blocking drug
or diuretic does not, in most
instances, significantly enhance
erectile function, and such patients
should be considered for direct ED
therapy with sildenafil.
Stable angina patients usually
REVIEWS IN UROLOGY S45
Managing Cardiac Disease and ED continued
have a functional reserve that
exceeds the demands of coitus.
This should be confirmed by exer-
ciseEKG testing. Antianginal
medications (NOT INCLUDING
NITRATES) can increase this func-
tional reserve.
The success of coronary revascular-
ization procedures may be evaluated
by exerciseEKG testing and with
imaging, if indicated.
Post-MI patients who are 68 weeks
post-event and who are asympto-
matic on post-MI stress testing, are
at low risk and should be encour-
aged to resume sexual activity
with ED treatment, if indicated.
Exercise training will most probably
reduce the small cardiac event risk
of coitus in this patient group.
Conclusions
Studies have demonstrated that
coitus requires a moderate level of
cardiac workload and myocardial
oxygen demand and carries a real
but very small absolute risk of trig-
Summary of Discussion Following
Dr. Steins Presentation
Discussion began with a direct ques-
tion by Dr. Sadovsky to Dr. Stein: So,
since you cant predict the patient who
is going to have a plaque rupture with
their sexual activity, whats your final
word? How do you advise a clinician
to actually measure his patients risk
of MI with sexual activity?"
Dr. Stein acknowledged the fear
among physicians that they might be
sued by spouses of patients who died
during coitus, that they would be
held liable for giving the sildenafil
and allowing sexual activity to begin.
He added, I think if you can show
you followed acceptable guidelines,
S46 VOL. 4 SUPPL. 3 2002 REVIEWS IN UROLOGY
gering an MI. With the availability of
sildenafil, it is a clinically important
requirement for physicians who treat
sexual dysfunction to be familiar with
this data as well as the guidelines for
the safe resumption of sexual func-
tion in ED patients.
References
1. Feldman HA, Goldstein I, Hatzichiristou DG, et
al. Impotence and its medical and psychologi-
cal correlates: results of the Massachusetts Male
Aging Study. J Urol. 1994;151:5461.
2. Dabuwala CB, Kumar A, Pierce JM. Myocardial
infarction and its influence on male sexual
function. Arch Sex Behav. 1986;15:499504.
3. Greenstein A, Chen J, Miller H, et al. Does
severity of ischemia coronary artery disease
correlate with erectile dysfunction? Int J Impot
Res. 1997;9:123126.
4. Cheitlin MD, Hutter AM, Brindis RG, et al.
ACC/AHA Expert Consensus Document. Use of
sidenafil (Viagra) in patients with cardiovascu-
lar disease. J Am Coll Cardiol.
1999;33:273282.
5. The Heart and Stroke Foundation of Canada
and the Canadian Cardiovascular Society. A
statement on the use of sildenafil in the man-
agement of sexual dysfunction in patients with
cardiovascular disease. March 9, 1999.
Available at: http://www.ccs.ca/society/posi-
tion/viagra.cfm. Accessed February 21, 2002.
6. DeBusk R, Drory Y, Goldstein I, et al.
Management of sexual dysfunction in patients
with cardiovascular disease: recommendations
of the Princeton Consensus Panel. Am J
Cardiol. 2000;86:175181.
you will be on better legal grounds in
terms of reasonable medical safety."
However, he added that one can
never be perfectly confident that a
patient will not have an MI, and
there is no evidence that very elabo-
rate testing is going to provide that
absolute confidence.
Dr. Stein continued, ED does pre-
dict people who go on to have heart
attacks; the Massachusetts Male
Aging Study data showed that
impressively (see article text). Dr.
Steins sense is that ED patients
probably fit the profile of the early
peripheral vascular disease or early
cerebrovascular disease patient,
where they have shown that they
7. Bartlett JR. Physiologic responses during
coitus. J Appl Physiol. 1956;9:496472.
8. Masters WH, Johnson VE. Human Sexual
Response. Boston: Little, Brown and Co; 1966.
9. Hellerstein HK, Friedman EH. Sexual activity
and the postcoronary patient. Arch Intern Med.
1970;125:987999.
10. Stein RA. The effect of exercise training on heart
rate during coitus in the post myocardial infarc-
tion patient. Circulation. 1977;55:738740.
11. Nemec ED, Mansfield L, Kennedy JW. Heart rate
and blood pressure responses during sexual
activity in normal males. Am Heart J.
1976;92:274277.
12. Bohlen JG, Held JP, Sanderson MO, Patterson
RP. Heart rate, rate-pressure product, and oxy-
gen uptake during four sexual activities. Arch
Intern Med. 1984;144:17451748.
13. Mann S, Craig MWM, Gould B, Raftery EB.
Coital blood pressure in hypertensives
[abstract]. Circulation. 1980;62(suppl III):III37.
14. Ueno M. The so-called coition death. Nippon
Hoigaku Zasshi [The Japanese Journal of Legal
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15. Muller JE, Mittleman MA, Maclure M, et al.
Triggering myocardial infarction by sexual
activity: low absolute risk and prevention by
regular physical exertion. Determinants of
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16. Muller JE. Sexual activity as a trigger for car-
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Cardiol. 1999;84(5B):2N5N.
Johnston BL, Fletcher GF. Dynamic electrocar-
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have arterial atherosclerotic disease.
Stein said he thinks it is always
appropriate, with this population, to
speak to patients in terms of risk-
factor modification (lipid control,
etc) and to encourage that.
The study by Hellerstein and
Friedman (see article text) was, Dr.
Stein surmised, probably the begin-
ning of physicians realizing that
their patients should, in all instances,
safely resume sexual activity. Those
authors stated that the cardiac risk
was low, and that patients heart rates
were actually higher during the
course of normal daily activities.
Also, that study came out at about the
time that physicians were beginning
 Managing Cardiac Disease and ED

to realize that 60% of post-MI patients
did not resume sexual activity. Sixty
percent of patients, who were sexually
active prior to MI, either didnt resume
at all, or resumed sexual activity at a
far lower frequency than they had
before the MI.
Hence, Dr. Stein stressed the need
for physicians to actively counsel, to
overcome the public myth that sex
after MI is dangerous. After the intro-
duction of sildenafil, which made all
physicians aware that they have to talk
to their patients about sexual function,
came another, similar wake-up call to
cardiologists that they had to counter
this public myth. The feeling among
cardiologists, he said, is that if they
didnt mention it, that they were leav-
ing the myth unopposed. If I havent
said to them, You can safely and
should resume sexual activity, they
have a reasonable chance of thinking
that sex is not safe after their MI."

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