A 58-year-old man comes to the office for follow-up 2 months after a non-ST elevation myocardial infarction. During the hospitalization, he underwent cardiac catheterization with a percutaneous coronary intervention to the left anterior descending artery. The patient's subsequent hospital course was uncomplicated, and he has not had any recurrent chest pain, dyspnea, or dizziness. However, since hospitalization he has not been able to achieve an erection sufficient for sexual intercourse, which has never happened previously. The patient says, "I am still interested in sex, but maybe my heart is just not able to work as well as it used to." He continues to have spontaneous nocturnal erections, and reports a satisfying marriage with no significant marital discord. The patient has returned to work as an insurance agent and has experienced no difficulty climbing 2 flights of stairs at his workplace. Medical history is notable for type 2 diabetes mellitus, hypertension, and hyperlipidemia. Current medications include aspirin, clopidogrel, metformin, atorvastatin, isosorbide mononitrate, lisinopril, and carvedilol. He does not use alcohol or illicit drugs; he has a 40-pack-year smoking history but quit 8 weeks ago. Vital signs are within normal limits, and physical examination shows no abnormalities. Laboratory testing shows normal blood counts and serum chemistry studies, and hemoglobin A1c is 7.1%. Which of the following is the best next step in management of this patient's erectile dysfunction?

Question

A 58-year-old man comes to the office for follow-up 2 months after a non-ST elevation myocardial infarction.  During the hospitalization, he underwent cardiac catheterization with a percutaneous coronary intervention to the left anterior descending artery.  The patient's subsequent hospital course was uncomplicated, and he has not had any recurrent chest pain, dyspnea, or dizziness.  However, since hospitalization he has not been able to achieve an erection sufficient for sexual intercourse, which has never happened previously.  The patient says, "I am still interested in sex, but maybe my heart is just not able to work as well as it used to."  He continues to have spontaneous nocturnal erections, and reports a satisfying marriage with no significant marital discord.  The patient has returned to work as an insurance agent and has experienced no difficulty climbing 2 flights of stairs at his workplace.  Medical history is notable for type 2 diabetes mellitus, hypertension, and hyperlipidemia.  Current medications include aspirin, clopidogrel, metformin, atorvastatin, isosorbide mononitrate, lisinopril, and carvedilol.  He does not use alcohol or illicit drugs; he has a 40-pack-year smoking history but quit 8 weeks ago.  Vital signs are within normal limits, and physical examination shows no abnormalities.  Laboratory testing shows normal blood counts and serum chemistry studies, and hemoglobin A1c is 7.1%.  Which of the following is the best next step in management of this patient's erectile dysfunction?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfd1_0646_8f63_09d71659af3d_MD0005_00 Sexual activity can increase the risk of myocardial infarction due to the associated tachycardia and acute rise in blood pressure. However, most patients with uncomplicated myocardial infarction (ie, no recurrent angina, no arrhythmias, normal ventricular function) and successful revascularization are at low risk of cardiac complications and may resume normal sexual activity ~2 weeks following the initial cardiac event. Erectile dysfunction (ED) is common in patients with cardiovascular disease due to decreased penile blood flow, endothelial dysfunction, and vasoactive medications. However, this patient expresses significant apprehension regarding sexual activity following his cardiac event, and the sudden onset of ED and normal nonsexual nocturnal erections suggest a likely psychogenic etiology. Therefore, the initial management should include a more detailed psychological assessment and counseling, possibly with the assistance of a clinical psychologist. (Choice A) Routine sexual activity is associated with physical exertion of approximately 3-4 metabolic equivalents (METS), which is comparable to brisk walking or ascending 2 flights of stairs. This patient is asymptomatic with moderate exertion, and stress testing is not indicated. (Choice B) Chronic diabetes increases the risk for ED. However, tight glycemic control has not been shown to reverse established ED. Furthermore, this patient's control is near target, his ED has a likely psychogenic basis, and more aggressive diabetic management is unlikely to have a significant benefit. (Choice C) Phosphodiesterase-5 inhibitors (eg, sildenafil) are the first-line treatment for most patients with ED, including those with cardiovascular disease. However, these medications are contraindicated in patients taking nitrates (eg, isosorbide mononitrate) as concomitant use can cause a precipitous drop in blood pressure leading to syncope. (Choice E) Beta blockers (eg, carvedilol) are associated with an increased risk of ED. However, they are strongly recommended for patients with symptomatic atherosclerotic cardiac disease and should not be discontinued so soon after a myocardial infarction. Educational objective: Sudden onset of erectile dysfunction with normal nonsexual nocturnal erections suggests a likely psychogenic etiology. Initial management should include a detailed psychological assessment and counseling. References: Erectile dysfunction. (http://www.ncbi.nlm.nih.gov/pubmed/27929275)

A 58-Year-Old Man Comes to the Office for Follow-Up 2