Sex, the Heart and Erectile Dysfunction

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Sex, the Heart and Erectile Dysfunction

• Graham Jackson
• Consultant Cardiologist
• Guys St Thomas Hospital, London, UK.

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ED The size of the problem

• 1995 152 million men worldwide
• 2025 322 million men worldwide

Ayta et al BJU Int 1999 8450-6
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ERECTILE DYSFUNCTION Increases with Age
Complete
Moderate
Minimal
75
50
Prevalence.
25
0

• 40 45 50 55 60 65 70

Age
Massachusettes Male Aging Study, Feldman HA et
al, J. Urol 1994
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Erectile Dysfunction

• Leads to depression, anxiety, loss
  of self-esteem
• Affects both partners
• In 20 of relationship
  breakdown, ED is responsible

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Common Misunderstandings

• Its all in the mind
• My partner thinks I dont love her anymore
• Nothing can be done about it
• Its an old mans problem

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Major Causes of Erectile Dysfunction
Endocrine disorders 6
Multiple sclerosis 3
Spinal Cord Injury 8
Diabetes Mellitus 40
Radical Surgery 13
Vascular Disease 30
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ED and Cardiac Patients

• MMAS men with cardiovascular disease, diabetes
  or hypertension 4 times the incidence of complete
  ED
• Myocardial infarction 44
• Untreated hypertension 17
• Treated hypertension 25
• ED increases with increasing CAD

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Treating Sexual Dysfunction in the Cardiac Patient

• Is sex safe in general?
• Is sex safe for the individual?
• How do we individualise risk?
• Can ED be safely treated in the cardiac patient?

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Energy Requirements of Sexual Activity Summary
of Data

• In general, the physiological cost of sexual
  activity with the usual partner is similar to
  that of exercise of mild-to-moderate intensity or
  most middle-aged men, with or w/o coronary artery
  disease
• Average peak heart rate 110130 beats/min
• Average peak systolic blood pressure 150180 mm
  Hg
• Average peak rate-pressure product 16,00023,000
• Average metabolic expenditure
• 23 METS before orgasm
• 34 METS during orgasm
• 56 METS upper range
• The upper range can be expected in younger
  individuals the lower range- in older
  individuals or in long-established relationships

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MET equivalents as a guide to relating daily
activity to sexual activity
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ETT and Sex

• If patients can achieve 5 to 6 METS without
  significant ischaemia (gt 2 mm ST-segment
  depression), arrhythmias or a fall in SBP they
  are not at risk during their normal sexual
  activity
• 4 minutes of the standard Bruce protocol exercise
  ECG

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Risk Factors for CAD and ED
Coronary Artery Disease (CAD)
ED

• Age
• Dyslipidemia
• HTN
• Diabetes
• Smoking
• Sedentary lifestyle
• Obesity
• Depression
• Coronary artery disease (CAD), peripheral
  vascular disease

• Age
• Dyslipidemia
• Hypertension (HTN)
• Diabetes
• Smoking
• Sedentary lifestyle
• Obesity
• Depression
• Male gender

Is ED an independent marker of endothelial
dysfunction and early, systemic vascular disease?
CADcoronary artery disease. Billups KL. Curr Sex
Health Rept. 20041137-141.
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Artery size and Atherothrombosis

• Artery Size (mm) Clinical Event
• Penile 1-2 ED
• Coronary 3-4 CAD
• Carotid 5-7 TIA/Stroke
• Femoral 6-8 Claudication

Montorsi et al Eur
Urol 2003 44352-4
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The Penile Stress TestA window to the hearts of
Man? Adapted from Priztker Circulation
2000100P3751
50 Men with ED Asymptomatic for CAD
28 Positive ETT
20 Coronary Angiography
7 men moderate 2-vessel CAD
7 men significant 1-vessel CAD
6 men severe CAD
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ED Prevalence, Time of Onset in 300 consecutive
men with acute chest pain and CAD

• Mean age 62.5 years
• ED prevalence 49 (147/300)
• ED before CAD symptoms 99 (67)
• Mean time interval ED to CAD 38.8
  months (1-168)

Montorsi et al Eur Urol
200344360-5
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• The recognition of ED as a warning sign of
  silent vascular disease has led to the concept
  that a man with ED and no cardiac symptoms is a
  cardiac (or vascular) patient until
  proven otherwise.
• Princeton II Jackson G et al. 2006. J Sex Med
  328-36

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Strategy I

• Ask routinely

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Suggested Introductory Questions on Sexual
Function

• It is quite normal for some men with
  cardiovascular disease to experience problems at
  some stage with getting an erection. Is this a
  problem youve experienced? If so, is it
  something you would like to do something
  about?
• Some men may have sexual difficulties after
  bypass surgery, a heart attack or from medication
  - have you experienced any problems?

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Treatments

• PDE 5 Inhibitors
• MUSE
• Injection Therapy
• Vacuum Pumps
• Surgery

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(No Transcript)
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inhibitor
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PDE 5 Inhibitors Essential Differences
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Sildenafil in Cardiac Patients

• Success Rates
• 80-85 overall (placebo 15-20)
• Diabetes 60
• Depression 76-80
• Hypertension on therapy 70-75
• Ischaemic heart disease 80
• AVOID NITRATES, NO NITRIC OXIDE DONORS

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Princeton II Consensus Statement 4

• Body of safety data for sildenafil in patients
  with concomitant ED and CVD, including CHF and
  CAD, is substantial.
• The lesser amount of data available concerning
  the safety of tadalafil and vardenafil has not
  indicated important safety concerns to date.

Kostis JB et al. Am J Cardiol. 200596313-321
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Male Cardiovascular Health ClinicJan 2001
August 2005

• Patients seen 507
• Low Risk 454 (90)
• Treated with follow-up 342
• Efficacy for SI 291 (85)
• PDE5 Inhibitor 277 (95)
• Acute events 0

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Physical Activity and Prevalence of ED
Strategy 3 Prevention
Proportion of Men With ED ()


Physical Activity
Odds ratio(OR)0.46(CI, 0.27-0.76).OR0.35(CI,
0.22-0.54). Nicolosi A et al. Int J Impot Res.
200315253-257.
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Conclusion

• Mechanism is endothelial dysfunction in the
  majority. ED ED
• Treatment options
• - No increased risk in properly assessed
  patients
• A cardiac problem is not a contraindication to
  sex
• - Cardiologists have an important role in
  counselling and advising their patients
• - Guidelines exist to help
• This is too important to be left to the
  urologists
• - A collaborative approach is needed

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• Dear Emma,
• I was married in the Philippines in July 2005 ,
  something I would only have dreamed about until I
  came to your clinic, Dare I say this? My wife
  is 18 years younger than me, and very fit in all
  departments, Boy oh Boy did we have a really
  great honeymoon? We sure did. Please tell Dr.
  Jackson from me, I was as good, or even better
  than Way back when I most certainly didnt let
  the side down -
• Joking Apart May I say a big THANK YOU,
  without the kind care, consideration,
  professionalism of your clinic towards making a
  man out of me again I certainly would have
  never gained a priceless gift someone to love
  and be loved, my new wife. No more nuptial
  shame, embarrassment, sickening self-loathing
  for being this inadequate, incomplete,
  incompetent half-man. Always One Big Guilty
  Secret. Too Scared to Woo a Lady. No More.
• Thank you both Again. Very Best Wishes,