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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Erectile dysfunction is more prevalent in patients with cardiovascular disease

  • Leriche’s syndrome and vascular impotence occasionally cause erectile dysfunction

  • Sexual activity is a form of exercise and can precipitate angina or acute coronary syndromes

GENERAL CONSIDERATIONS

  • Erectile dysfunction can be primary or secondary to risk factors, such as hypertension, diabetes, cigarette smoking, and hypercholesterolemia

  • Little is known about female sexual dysfunction in cardiovascular disease

  • Erectile dysfunction increases with age

  • New pharmacologic treatments for erectile dysfunction have exposed sexually inactive men to the risks of sexual activities

  • Sexual intercourse increases oxygen demand by about 3–5 metabolic equivalents

  • Any patient who is free of ischemia on submaximal exercise test can safely engage in sexual activity

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Erectile dysfunction

  • Dizziness, syncope after sexual activity

  • Angina with sexual activity

  • Vaginal dryness

PHYSICAL EXAM FINDINGS

  • Hypotension

  • Tachycardia

  • S4

DIFFERENTIAL DIAGNOSIS

  • Psychogenic impotence

  • Medication-induced sexual dysfunction

  • Autonomic neuropathy

  • Severe peripheral atherosclerosis

  • Hypogonadism

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Low serum testosterone in some men

  • Low estrogen levels in some women

ELECTROCARDIOGRAPHY

  • ECG: may show signs of myocardial ischemia/infarction

IMAGING STUDIES

  • Echocardiography: may show left ventricular hypertrophy or dysfunction

DIAGNOSTIC PROCEDURES

  • Coronary angiography may be necessary

TREATMENT

CARDIOLOGY REFERRAL

  • Presence of cardiac disease

HOSPITALIZATION CRITERIA

  • Acute coronary syndromes

  • Syncope

  • Persistent hypotension

MEDICATIONS

  • Oral sildenafil (25–100 mg), vardenafil, and tadalafil are effective for erectile dysfunction (caution with concurrent nitroglycerin use)

  • Give transurethral or cavernosal alprostadil (prostaglandin E1) if nitrates cannot be stopped

  • Testosterone may help some men

  • Topical estrogen creams may help some women

THERAPEUTIC PROCEDURES

  • Percutaneous revascularization may be necessary

SURGERY

  • Coronary bypass surgery may be indicated

MONITORING

  • ECG monitoring in hospital as appropriate

DIET AND ACTIVITY

  • Low-fat diet

  • Activity predicted by cardiac disease

  • In general, a negative exercise stress test permits sexual intercourse

ONGOING MANAGEMENT

HOSPITAL DISCHARGE CRITERIA

  • Resolution of problem

  • Successful revascularization

FOLLOW-UP

  • Predicated by cardiac disease status

COMPLICATIONS

  • Erectile dysfunction drugs can precipitate dangerous hypotension in certain circumstances, such as concomitant nitroglycerin use

  • Sexual activity can lead to acute coronary syndromes

PROGNOSIS

  • Myocardial ischemia caused by ...

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