A 54-year-old man comes to the office due to erectile dysfunction. For the last 6 months, the patient has had progressive difficulty maintaining an erection long enough to have satisfying sexual intercourse. In addition, he has had loss of libido and a decrease in early morning erections. Medical history is significant for hyperlipidemia and coronary artery disease. The patient was admitted for an acute coronary syndrome 7 months ago, and a drug-eluting stent was placed in the right coronary artery. A follow-up treadmill cardiac stress test was negative; he is able to walk briskly for 30 minutes daily without developing angina or other symptoms. Current medications include metoprolol, atorvastatin, aspirin, and ticagrelor. Blood pressure is 122/70 mm Hg and pulse is 66/min. Cardiopulmonary examination is unremarkable except for mildly decreased pedal pulses on the right. He has normal testicular size, normal secondary sexual characteristics, and no gynecomastia. Laboratory results are as follows: Which of the following is the best next step in treating this patient's erectile dysfunction?

Question

A 54-year-old man comes to the office due to erectile dysfunction.  For the last 6 months, the patient has had progressive difficulty maintaining an erection long enough to have satisfying sexual intercourse.  In addition, he has had loss of libido and a decrease in early morning erections.  Medical history is significant for hyperlipidemia and coronary artery disease.  The patient was admitted for an acute coronary syndrome 7 months ago, and a drug-eluting stent was placed in the right coronary artery.  A follow-up treadmill cardiac stress test was negative; he is able to walk briskly for 30 minutes daily without developing angina or other symptoms.  Current medications include metoprolol, atorvastatin, aspirin, and ticagrelor.  Blood pressure is 122/70 mm Hg and pulse is 66/min.  Cardiopulmonary examination is unremarkable except for mildly decreased pedal pulses on the right.  He has normal testicular size, normal secondary sexual characteristics, and no gynecomastia.  Laboratory results are as follows:  Which of the following is the best next step in treating this patient's erectile dysfunction?

Quizplus · Accepted Answer

Sexual activity can increase the risk of myocardial infarction due to tachycardia and the 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 recurrent cardiac events and may resume normal sexual activity at least 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. First-line treatment for most patients with ED, including those with cardiovascular disease, is a phosphodiesterase-5 (PDE-5) inhibitor (eg, sildenafil). These medications are safe and effective in treating ED in low-risk patients with cardiovascular disease. However, PDE-5 inhibitors are contraindicated in patients taking nitrates as concomitant use can cause a precipitous drop in blood pressure, leading to syncope. Coadministration of alpha blockers with PDE-5 inhibitors can also cause severe hypotension. Other common side effects of PDE-5 inhibitors include headaches and disturbances in vision and hearing. (Choice A) Patients with coronary artery disease who are at increased risk should refrain from sexual activity until they have been appropriately evaluated and stabilized. This includes those with ongoing stable or unstable angina, incomplete revascularization, left ventricular dysfunction or symptomatic heart failure, high-risk arrhythmias, or very recent (<2 weeks) myocardial infarction. (Choice B) Alprostadil (prostaglandin E1) treats ED by inducing vasodilation of the cavernosal arteries. However, alprostadil is a second-line agent as it is less convenient and likely less effective than PDE-5 inhibitors. (Choices D and E) Cardioselective beta blockers and high-intensity statins are crucial for secondary prevention of cardiovascular events in patients with acute coronary syndrome. These drugs should not be stopped unless patients are completely intolerant or experience severe side effects. (Choice F) Testosterone therapy may be useful in ED associated with low serum testosterone levels. This patient's testosterone level is normal, and the loss of libido may be a secondary consequence of ED. Educational objective: Erectile dysfunction is common in patients with cardiovascular disease. First-line treatment includes phosphodiesterase-5 (PDE-5) inhibitors (eg, sildenafil). PDE-5 inhibitors are contraindicated in patients taking nitrates or alpha blockers as concomitant use can cause severe hypotension.

A 54-Year-Old Man Comes to the Office Due to Erectile