doi: 10.1161/01.CIR.0000152482.71628.51
(Circulation. 2005;111:e18-e19.)
© 2005 American Heart Association, Inc.
Correspondence |
Letter Regarding Article by Gazzaruso et al, "Relationship Between Erectile Dysfunction and Silent Myocardial Ischemia in Apparently Uncomplicated Type 2 Diabetic Patients"
St. Thomas’ Hospital, London, United Kingdom
Mayo Clinic, Rochester, Minn
St. Thomas’ Hospital, London, United Kingdom
The article by Gazzaruso et al1 raises a number of issues. The relationship of erectile dysfunction (ED) to coronary heart disease (CHD) has been well established in a multiplicity of publications, and as such, similar findings in type 2 diabetes are no surprise and have been described previously.2 Indeed, the International Index of Erectile Function score significantly correlates with the degree of coronary atheroma burden in patients presenting with ED.3
The definition of silent myocardial ischemia used in the study by Gazzaruso et al1 does not agree with other standard definitions and actually describes patients with coronary arterial disease of unquantified severity in whom no critical ischemia after exercise or pharmacological challenge could be demonstrated, which is similar to cohorts without overt CHD that have been described in the literature. The statistical analysis of the data demonstrating an association of CHD or ED with dichotomously divided cardiovascular risk factors is likely to be underpowered and prone to type I error because of the arbitrary nature of data before initiating treatment. It would be useful to know whether any relationship was present when original data, log-transformed where appropriate, were used as the independent variables.
The recommendations about assessing cardiovascular risk in patients with ED before prescribing phosphodiesterase (PDE)-5 inhibitors are an overinterpretation of the data and conflict with established guidelines.4 The cardiovascular safety of PDE-5 inhibitors in ED is well established and reflects their origin as antianginal medications.5 Similarly, the requirement for exercise testing reflects the exertion likely involved in sexual intercourse, and thus screening for limiting angina as well as investigating to define the degree of atherosclerosis.
The high prevalence of ED in patients with diabetes reflects their high atheroma burden and the degree of generalized endothelial dysfunction. Patients should not be denied PDE-5 inhibitors or other treatments for ED because of the overstated risks of acute cardiac events.
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1. Gazzaruso C, Giordanetti S, De Amici E, Bertone G, Falcone C, Geroldi D, Fratino P, Solerte SB, Garzaniti A. Relationship between erectile dysfunction and silent myocardial ischemia in apparently uncomplicated type 2 diabetic patients. Circulation. 2004; 110: 22–26.
2. Feldman HA, Johannes CB, Derby CA, Kleinman KP, Mohr BA, Araujo AB, McKinlay JB. Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Prev Med. 2000; 30: 328–338.[CrossRef][Medline] [Order article via Infotrieve]
3. Solomon H, Man JW, Wierzbicki AS, Jackson G. Relation of erectile dysfunction to angiographic coronary artery disease. Am J Cardiol. 2003; 91: 230–231.[CrossRef][Medline] [Order article via Infotrieve]
4. DeBusk R, Drory Y, Goldstein I, Jackson G, Kaul S, Kimmel SE, Kostis JB, Kloner RA, Lakin M, Meston CM, Mittleman M, Muller JE, Padma-Nathan H, Rosen RC, Stein RA, Zusman R. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of The Princeton Consensus Panel. Am J Cardiol. 2000; 86: 175–181.[CrossRef][Medline] [Order article via Infotrieve]
5. Jackson G. Sildenafil (Viagra): new data, new confidence in treating erectile dysfunction in the cardiovascular patient. Int J Clin Pract. 2002; 56: 75.[Medline] [Order article via Infotrieve]
Response
Internal Medicine Unit, IRCCS Maugeri Foundation Hospital, Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
Cardiology Unit, University of Pavia, Pavia, Italy
Internal Medicine, Vascular and Metabolic Diseases, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
Department of Internal Medicine and Medical Therapeutics, University of Pavia, Pavia, Italy
Diabetes Centers of Pavia and Mede, Azienda Ospedaliera Province of Pavia, Pavia, Italy
We thank Jackson and colleagues for their interest, but we respectfully disagree with their comments. As for the inclusion criteria, we included apparently uncomplicated diabetic patients with silent myocardial ischemia resulting from significant coronary artery disease that was angiographically documented.1 Silent ischemia was assessed by exercise testing according to the current standard procedures. Our study protocols, reported in our previous investigations,1 were designed according to the clinical guidelines of the American Diabetes Association. As for the statistical analysis, we believe that it provided reliable results. The dichotomization of the variables was not arbitrary. Indeed, each dichotomization (presence/absence of a risk factor) has been justified by a specific reference and has been performed according to the current guidelines. Even when we repeated the multivariate analysis according to the suggestions of Jackson and colleagues we found similar results. Forward stepwise regression analysis showed that the International Index Erectile Function score (ß=–0.39; P=0.0000), smoking (ß=0.27; P=0.0000), HDL (ß=–0.20; P=0.0001), apo(a) isoforms’ molecular weight (ß=–0.16; P=0.0013), LDL (ß=0.15; P=0.0019), and albumin excretion rate (ß=0.11; P=0.0421) were independently associated with silent ischemia. To assess silent myocardial ischemia, we suggested exercise testing before initiating treatment for erectile dysfunction (ED), especially in diabetic patients with additional risk factors. Our suggestions are not far from those of the Princeton Consensus Panel guidelines, which recommend exercise testing in subjects with 
3 risk factors, including diabetes. Nevertheless, diabetes is a "coronary artery disease–equivalent" condition and in diabetic patients, ischemia is often silent. Diabetic patients with predictors of silent ischemia may be unsuspecting "cardiac patients." Thus, in these patients it is important to prevent any risk of cardiac event during sexual intercourse, as also recommended by Arruda-Olson and Pellikka.2 Solomon et al stated: "...although the absolute risk of a cardiac event in cardiac patients is small during sexual activity, this risk must to kept to a minimum by exercise testing patients before initiating ED treatment."3 We do not want to deny treatment for ED. On the contrary, our article emphasizes that it is important to assess ED in all diabetic patients. The systematic assessment of ED may lead to the identification of a higher number of patients who should be screened for silent ischemia. Moreover, it is possible to find a greater proportion of patients to treat for ED and thus improve their quality of life.
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TopReferencesReferences |
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1. Gazzaruso C, Giordanetti S, De Amici E, Bertone G, Falcone C, Geroldi D, Fratino P, Solerte SB, Garzaniti A. Relationship between erectile dysfunction and silent myocardial ischemia in apparently uncomplicated type 2 diabetic patients. Circulation. 2004; 110: 22–26.
2. Arruda-Olson AM, Pellikka PA. Appropriate use of exercise testing prior to administration of drugs for treatment of erectile dysfunction. Herz. 2003; 28: 291–297.[Medline] [Order article via Infotrieve]
3. Solomon H, Man J, Martin E, Jackson G. Role of exercise treadmill testing in the management of erectile dysfunction: a joint cardiovascular/erectile dysfunction clinic. Heart. 2003; 89: 671–672.
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