This document provides recommendations for evaluating and managing erectile dysfunction (ED) in patients with cardiovascular disease (CVD). It finds that ED often precedes CVD by 2-3 years and is associated with increased CVD risk and mortality. It recommends assessing all men with ED for CVD risk factors and stratifying risk. High risk patients should undergo stress testing. Lifestyle changes like weight loss and exercise can improve ED. Aggressive treatment of hypertension, diabetes and hyperlipidemia may also benefit ED patients. Managing cardiovascular health should take priority over initiating ED treatment. Phosphodiesterase 5 inhibitors are first-line ED therapy for most patients with CVD. Testosterone should be measured in all ED patients and supplementation may help ED in some

1. Treatment of Sexual dysfunction associated with CVD Graham Jackson Consultant Cardiologist Guy’s & St Thomas’ Hospital, London, UK.

4. ED Predicts coronary events 1400 men 40-75, with no known CAD 10yr follow up Inman et al Mayo Clin Pr 2009;84:108-113 Age Group ED at baseline No baseline ED 40-49 48.52 (1.23-269.26) 0.94 (0.02-5.21) 50-59 27.15 (7.40-69.56) 5.09 (3.38-7.38 ) 60-69 23.97 (11.49-44.10) 10.72 (7.62-14.66) 70+ 29.63 (19.37-43.75) 23.30 (17.18-30.89) CAD events per 1000 pt years with CI interval Inman et al Mayo Clin Pr 2009

19. Figure 1. Management of man with ED and no known CVD *Determine ED severity based on International Index of Erectile Function (IIEF): mild 17-21; mild to moderate 12-16; moderate 8-11; severe 1-7 Consider cardiac evaluation if severe irrespective of Framingham score. † Incorporate age, gender, total cholesterol, HDL cholesterol, smoking, systolic BP, BP therapy (see appendix sample calculation) Sexual Enquiry of All Men E.D. (No known CVD)* Essential Checks: Age, BP, glucose, lipids, testosterone, smoking Additional Checks: BMI, waist circumference, exercise, alcohol, diet, family history Framingham Risk † Low (<10%) Intermediate (10-20%) High (>20%) Lifestyle Advice Lifestyle advice, medication and non-invasive risk evaluation (e.g. stress testing) Lifestyle advice, medication, and cardiologist

24. Metabolic Syndrome increases CV morbidity and mortality 21 9 4.8 5.5 2.1 1.4 0 5 10 15 20 25 CHD Previous MI Previous stroke 4.6 2.2 12 18 0 5 10 15 20 25 Total mortality CV mortality Incidence (%) Prevalence (%) Metabolic syndrome present Metabolic syndrome absent Isomaa B, et al. Diabetes Care 2001; 24: 683–689 . p<0.001 p<0.001 p<0.001 p<0.001 p<0.001 Morbidity Mortality

31. Risk Factor Modification and ED Esposito et al, JAMA, 2004, 291: 2978-3012

33. ASCOT: Baseline Characteristics Age* (years) Male (%) Caucasian (%) SBP* (mm Hg) DBP* (mm Hg) TC* (mmol/L [mg/dL]) LDL-C* (mmol/L [mg/dL]) TG* (mmol/L [mg/dL]) HDL-C* (mmol/L [mg/dL]) Number of risk factors* 63.1 ± 8.5 81.1 94.6 164.2 ± 17.7 95.0 ± 10.3 5.5 ± 0.8 (213 ± 31) 3.4 ± 0.7 (131 ± 27) 1.7 ± 0.9 (150 ± 80) 1.3 ± 0.4 (50 ± 27) 3.7 ± 0.9 Characteristic Atorvastatin (n=5168) 63.2 ± 8.6 81.3 94.7 164.2 ± 18.0 95.0 ± 10.3 5.5 ± 0.8 (213 ± 31) 3.4 ± 0.7 (131 ± 27) 1.6 ± 0.9 (142 ± 80) 1.3 ± 0.4 (50 ± 27) 3.7 ± 0.9 Placebo (n=5137 ) *Mean ± SD Sever PS, Dahlöf B, Poulter N, Wedel H, et al, for the ASCOT Investigators. Lancet. 2003;361:1149-58

37. Obesity Diabetes Hypertension Dyslipidemia ED: BAROMETER OF MEN ’ S HEALTH: The Deadly Quartet

39. Metabolic equivalent (METs) of Selected Daily Activity compared to Sexual Activity

40. “ The same old story…” Cost of Sexual Activity: The case for a distinction “ New fling” Familiar partner Unfamiliar partner + Familiar setting + Unfamiliar setting METS 2-3 METS 5-6 + Familiar meal + Unfamiliar meal

41. Cardiovascular Changes during Sexual Activity Simple everyday guidelines Walking 1 mile in 20’  3.5 METS Briskly climbing 2 flights of stairs (20 steps in 10 seconds)  3 METS “ The stair-climbing test” (Larson, 1980) Digging in the garden  5 METS

42. Figure 2. Management of ED in patient with known CVD *Based on patient history per Princeton II (Kostis et al. 2005) † Sexual activity equivalent to walking 1 mile on the flat in 20 minutes, briskly climbing 2 flights of stairs (10 seconds) ‡ Sexual activity equivalent to 4 minutes of the Bruce treadmill protocol Sexual Enquiry of All Men E.D. and known CVD Clinical evaluation to determine CV risk with sexual activity* Low CV risk Intermediate or indeterminate risk High risk Exercise ability † Exercise stress testing ‡ Sexual activity deferred; see cardiologist Initiate/resume sexual activity, treat ED Low risk High risk

50. Take Home Message E.D. E rectile D ysfunction ED ucation E arly D etection E ndothelial D ysfunction E arly D eath