Results of November survey 2006

ED is now considered an early manifestation of a largely subclinical vascular disorder and ED patients present a higher risk for coronary artery disease (CAD). However, “low risk” patients can immediately initiate a treatment for ED without further evaluation, while “intermediate and high risk” patients need to be referred for cardiologic assessment and treatment.

Which of the following patients have a “low risk” and can initiate a treatment for ED without any additional cardiovascular evaluation?

1) 71 y.o. man asymptomatic for CAD, cigarette smoker (10/day), affected with well controlled hypertension and diabetes.: Percentage of answers: 56,0%
2) 58 y.o. man with history of mild, stable angina pectoris.: Percentage of answers: 25,0%
3) 66 y.o. men with a single episode of myocardial infarction 5 weeks ago: Percentage of answers: 19,0%
4) 57 y.o. man with instable angina pectoris: Percentage of answers: 0%

Comments

The second Princeton Consensus Conference [Kostis JB et al. Am J Cardiol 2005;96:313-321] has highlighted the relation between erectile dysfunction (ED) and cardiovascular disease, stratifying ED patients in three risk classes. Low risk patients, that can immediately initiate a treatment for ED without further cardiac evaluation, present with:

Asymptomatic <3 Risk Factors*
Controlled hypertension
Mild, stable angina pectoris
Post-PTCA/CABG w/o residual ischemia
Recent Myocardial Infarction (>6 to 8 weeks)
LV dysfunction (NYHA class I)
Mild valvular disease

* age, hypertension, diabetes mellitus, cigarette smoking, dyslipidemia, sedentary lifestyle, family history of premature CAD

Most responders agree that an instable angina pectoris and a very recent myocardial infarction (answers 3 and 4) do not consent to immediately resume sexual activity or treat ED without further cardiologic assessment.
However, although asymptomatic for CAD, an aged man, whit history of cigarette smoking, hypertension and diabetes (Answer 1: definitely a very common type of ED patient!) cannot be considered at low risk and should be referred for cardiovascular evaluation.
On the contrary, in the case of a mild, stable angina pectoris (answer 2) the functional reserve is usually greater than required for sex. In this patients a non-invasive cardiovascular investigation, although non mandatory, could be suggested, but it should not delay the initiation of ED treatment, i.e. an ED patient with a mild, stable angina can be regarded as a low risk one.
Of course, the only major “caveat” in this case would be the possible use of nitrates that should be replaced with alternative treatment before prescribing PDE5i.