The issue of sexual problems in heart patients is already ignored, and media sensationalism about sildenafil (Viagra) may discourage patients from pursuing viable treatments, said Lars Ryden, MD, president of the European Society of Cardiology, at the society’s annual meeting in Barcelona. “What is being done in the press is scaring people from using what could do a lot for them,” he said.
“Impotence is a disease and should be treated.” Physicians, he said, frequently do not respond to their patients’ requests for help with the problem of impotence because they are uneasy about talking to patients about their sex lives or because they do not see an ability to perform or to enjoy sex as a real health issue to be addressed by cardiologists.
Although the risk of developing impotence increases with age to ≈15% in men aged 70, disease and medications contribute more than age, as do psychological factors, alcohol, and tobacco use. Cardiologists should not ignore the problem, because indications are that as many as 39% of their male patients between age 40 and 70 suffer severe erectile dysfunction, said Dr Ryden. (Heldman HA, et al. J Urol. 1994;151:54–61)
Yet the issue of sexual activity by heart patients, particularly those who have had myocardial infarctions or strokes, has always been a matter in contention. In many cases, the male patient’s partner becomes concerned that sex is too stressful, said Dr Ryden.
“Exercise testing is important because it can reassure patients and spouses that it is safe to resume sexual intercourse again,” said Suzanne Oparil, MD, professor of medicine at the University of Alabama at Birmingham. In general, she said, sexual activity is no more dangerous than other physical exercise and can be resumed at the same time. “Ordinarily, sexual activity in a familiar environment with the usual partner is safe,” she said. Dr Ryden noted that sexual activity is roughly equivalent to 10 minutes of shoveling snow, a leisurely bicycle ride, or walking up a few flights of stairs. Although the risk cannot be ignored, he said, physicians must address the problem with their patients.
That does not mean “micromanaging” the sexual act itself, said Dr Oparil. Exercise training can minimize risk, she said. Patients should tell physicians of their concerns about resuming sex. She advised making the sexual activity easy and stopping if there is pain. However, she said, there is little reason to be concerned. “Driving is more dangerous than sex.”
The sexual problems of women heart patients are even more often ignored than those of men, she said. The meeting in Europe focused too little attention to those issues, she said, and she predicted that women’s issues will be put on the front burner soon. “We want to improve the quality of life,” said Dr Oparil.
In a press conference here, both US and European cardiologists agreed that impotence is a problem and that anecdotal reports of deaths and cardiovascular problems associated with sildenafil are counterproductive. However, Dr Ryden said that although physicians should use their own judgment, he thinks they should continue to prescribe sildenafil in the absence of scientific evidence that it is harmful in the presence of other drugs. “There are no reports to make us suspect any other drug interaction is of concern,” he said. (The interaction between nitrates and sildenafil is well-known and accepted.)
Dr Ryden said there needs to be a distinction between the problems associated with the physical activity involved in sexual intercourse and the side effects or interactions of sildenafil. “If a patient is sick enough, the ability and interest in having sex is decreased. In that case, the person is out of line in wanting Viagra. First, one must focus on the danger of physical exercise. If a patient is fit for sex, he is fit for Viagra.”
Melvin Cheitlin, MD, who chaired the joint American Heart Association/American College of Cardiology consensus panel on the use of sildenafil in patients with cardiovascular disease, advised caution, however. He said the two major US heart organizations have been inundated by questions about the safety of the drug’s use in patients with heart disease. The drug works by increasing the flow of blood in the corpus cavernosum of the penis and keeping it there, he said. “Sildenafil inhibits the breakdown of the chemical that causes (blood vessel) dilation.” Before it was licensed, it was tested in 3700 people, but those studies excluded people with recent stroke and heart attack, diabetes, or hypertension. “These people have not been adequately studied,” said Dr Cheitlin.
In fact, he said, erectile function itself has not been well studied in the population of men with cardiovascular disease. In the consensus statement, the AHA/ACC panel noted the already recognized interaction between nitrates and sildenafil and urged that the two not be prescribed together.
Dr Cheitlin said he is concerned about the inadequacy of studies in this population, many of whom may have sexual problems. For those physicians who want to prescribe the drug, he suggested reducing the dose to 25 mg, half that which is recommended, and within 1 to 2 hours after, giving a test dose and doing a stress tests to assure that the patient can use sildenafil without inducing ischemia. Because no one with heart failure was included in the studies, he advised caution to physicians who want to prescribe the drug in that group.
He said he would like to see more drug studies to look at possible interactions, such as those drugs that compete with sildenafil or interfere with its breakdown. For example, he said, erythromycin and cimetidine can prolong the activity of sildenafil in the bloodstream. There have also been concerns that sildenafil can interact with the cholesterol-lowering statins because of nitrous oxide normalization, Dr Cheitlin said.
One major issue that cardiologists cannot ignore is the possibility that their patients may be obtaining sildenafil over the Internet and without a direct physical examination. Even if a cardiologist does not think the patient is using sildenafil, he or she should caution him about drug interactions. In fact, he said, physicians cannot assume that patients are not using nitrates. In some populations, the use of amylnitrate (commonly called poppers) to enhance sexual experience is fairly common. Amylnitrate can interact with sildenafil because it is a nitrate, he said.
“Overall, it’s a question of the patient-doctor relationship,” said Arthur Garson, Jr, MD, MPH, president of the American College of Cardiology and senior vice president at Baylor College of Medicine in Houston. “In the United States and the world, there is a need for trust between physicians and patients. Patients and physicians need to level with one another. Patients have to be willing to say, ‘I am on this drug.’ This is about the whole patient, not just the heart.”
- Copyright © 1999 by American Heart Association