Treating Erectile Dysfunction After Myocardial Infarction May Be Safe
By Seema Gupta, MD, MSPH
Clinical Assistant Professor, Department of Family and Community Health, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV
Dr. Gupta reports no financial relationships relevant to this field of study.
SYNOPSIS: In a Swedish nationwide cohort study of men < 80 years of age hospitalized for myocardial infarction, treatment for erectile dysfunction with phosphodiesterase-5 inhibitors resulted in lower mortality and heart failure hospitalization.
SOURCE: Andersson DP, Trolle Lagerros Y, Grotta A, et al. Association between treatment for erectile dysfunction and death or cardiovascular outcomes after myocardial infarction. Heart 2017 Mar 9. pii: heartjnl-2016-310746.
Erectile dysfunction (ED) is a common clinical problem, with high prevalence in the general population, and increases with age. The prevalence can be as high as 37% in men 70-75 years of age and those with co-morbid medical conditions and risk factors, including cardiovascular disease, hypertension, dyslipidemia, and depression, tend to report a higher incidence.1 Although studies have demonstrated that ED may be an early warning sign of future cardiovascular events, data also show that cardiovascular disease and its risk factors increase the risk for later ED.2,3 The existence of ED in a patient may be an independent predictor of severe coronary heart disease since many men with ED exhibit early signs of coronary artery disease (CAD), and this group may develop more severe CAD than men without ED. Studies have estimated the time interval between the onset of ED symptoms and the occurrence of CAD symptoms and cardiovascular events to be two to three years and three to five years, respectively. Thus, ED is associated with increased all-cause mortality, primarily increased cardiovascular mortality.
ED in men after a myocardial infarction (MI) is estimated to occur in one-half to three-quarters of patients.4 It has been demonstrated that phosphodiesterase-5 (PDE-5) inhibitors such as sildenafil can improve erectile function in patients with stable CAD. However, whereas the use of sildenafil does not increase the rate of serious cardiovascular events or MI, the association between treatment for ED and death or cardiovascular outcomes after a first MI remains unknown.5
To investigate the association between treatment for ED, mortality, and cardiovascular outcomes, Andersson et al conducted a nationwide cohort study that included all men < 80 years of age (43,145 individuals) in Sweden who suffered a first MI between 2007 and 2013 without a prior history of MI or cardiac revascularization, and were hospitalized for it. Of these, 7.1% suffered from ED and were prescribed PDE-5 inhibitors or alprostadil for a mean 3.3 years of follow-up. Researchers found that compared with those not treated for ED, men with treatment demonstrated a 33% lower mortality (adjusted hazard ratio [HR], 0.67; 95% confidence interval [CI], 0.55-0.81) and 40% lower risk of hospitalization for heart failure (HR, 0.60; 95% CI, 0.44-0.82). The adjusted risk of death in men with one, between two and five, and more than five dispensed prescriptions of PDE-5 inhibitors was reduced by 34% (HR, 0.66; 95% CI, 0.38-1.15), 53% (HR, 0.47; 95% CI, 0.26-0.87), and 81% (HR, 0.19; 95% CI, 0.08-0.45), respectively, when compared to alprostadil treatment, which showed no association with mortality.
The first PDE-5 inhibitor, sildenafil, was discovered by accident about two decades ago when investigators were trying to develop a new treatment for angina. Interestingly, now it may be used to lower mortality and heart failure-related hospitalizations in patients with CAD suffering from ED. The most critical finding from this study is that it seems safe to prescribe PDE-5 inhibitors to men with ED following a first MI and this may be associated with a reduced mortality and heart failure hospitalization. In the study, only men treated with PDE-5 inhibitors had a reduced risk, which appeared to be dose-dependent. An important limitation is the contraindication to the use of PDE-5 inhibitors in patients taking nitrates of any form, regularly or intermittently. However, there should be some caution in interpreting the results and, in particular, attributing a causative role to the drugs since PDE-5 inhibitor use, as the authors suggested, may be a marker for patients who are healthier overall, as evidenced by an active sex life and the fact that they request the medications.
While it’s too early to recommend that all patients with a previous MI and not on nitrates should take PDE-5 inhibitors, there are some physiological beneficial effects of these drugs such as systemic vasodilatory properties leading to the reduction of systolic blood pressure, improving endothelial dysfunction, and platelet activation inhibition. These effects potentially can explain the lowered mortality and reductions in heart failure hospitalizations. These results are reassuring and should encourage further randomized, placebo-controlled studies with PDE-5 inhibitors post-MI, perhaps including women. Meanwhile, current patients with CAD who are not taking nitrates and are not deemed to be at high risk should be risk-stratified and can be treated safely for sexual dysfunction with PDE-5 inhibitors.
- Rosen RC, Fisher WA, Eardley I, et al; Men’s Attitudes to Life Events and Sexuality (MALES) Study. The multinational Men’s Attitudes to Life Events and Sexuality (MALES) study: I. Prevalence of erectile dysfunction and related health concerns in the general population. Curr Med Res Opin 2004;20:607-617.
- Jackson G, Boon N, Eardley, et al. Erectile dysfunction and coronary artery disease prediction: Evidence-based guidance and consensus. Int J Clin Pract 2010;64:848-857.
- Min JK, Williams KA, Okwuosa TM, et al. Prediction of coronary heart disease by erectile dysfunction in men referred for nuclear stress testing. Arch Intern Med 2006;166:201-206.
- Dhabuwala CB, Kumar A, Pierce JM. Myocardial infarction and its influence on male sexual function. Arch Sex Behav 1986;15:499-504.
- Morales A, Gingell C, Collins M, et al. Clinical safety of oral sildenafil citrate (VIAGRA) in the treatment of erectile dysfunction. Int J Impot Res 1998;10:69-73.
In a Swedish nationwide cohort study of men < 80 years of age hospitalized for myocardial infarction, treatment for erectile dysfunction with phosphodiesterase-5 inhibitors resulted in lower mortality and heart failure hospitalization.
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