1. Section V: Erectile dysfunction: The patients you see
PDE5 inhibitors: Onset and duration of activity
Content Points:
Sildenafil has an onset of 30 to 60 minutes and duration of 4 hours.48
Tadalafil has a similar onset, but a substantially longer duration of 24 hours.49
Vardenafil's onset and duration have not been reported to date.

2. Importance of vascular clues
Content Points:
ED and CVD share many important and common risk factors, including diabetes mellitus, hypertension, dyslipidemia, and smoking.13
Vascular and endothelial injuries seen in the coronary arteries are also likely to occur in the cavernosal arteries (the primary arteries supplying penile erectile tissue).
Therefore, tests of erectile status can be important predictors of clinically silent but progressive forms of coronary, peripheral, or cerebrovascular disease as well as hypertension, diabetes, or other endocrine disorders.

3. Energy requirements (METS) of selected physical activities
Content Points:
METS are the standard clinical measure of exertion (1 MET = resting state). Sexual activity is often equated with an exercise workload of 2-3 METS in the pre-orgasmic phase and 3-4 METS during the orgasmic phase. However, the physical exertion required for sexual activity differs widely among individuals.50
While peak coital heart rate in healthy individuals was found to be substantially less than peak treadmill heart rate, heart rate in patients with ischemic heart disease can exceed that measured by treadmill exercise.
CV symptoms induced by sexual activity occur only rarely in individuals who have not experienced similar symptoms at a level of exercise testing equivalent to 6 METS.
The absolute risks of coition-induced MI or death are extremely low-about 2 chances/million/hr in healthy middle-aged individuals and 20 chances/million/hr in high-risk patients with ischemic heart disease.

4. Onset of MI following sexual activity
Content Points:
Muller et al evaluated the relative risk (RR) of nonfatal MI following sexual activity in the general population versus patients with prior CHD.51
The bars show time from sexual activity to onset of MI among patients with CHD, with relative risks for each 1-hour period before onset of MI. The dotted line shows the baseline risk determined from the general population.
The risk of MI increases only during the first 2 hours after sexual activity (RR = 2.5%; 95% CI, 1.7 to 3.7).
The risk of triggering onset of MI among patients with a history of prior angina or prior MI was no greater than for individuals without prior cardiac disease.
Sexual activity probably contributed to onset of MI in only 0.9% of observed cases.

5. Sexual activity and MI: Protective effect of regular exercise
Content Points:
Muller et al also examined potential modifiers of risk for MI onset. Of the variables measured, the only statistically significant characteristic was recurring physical exertion of 6 or more METS.51
The risk of MI onset 2 hours following sexual activity decreased depending on the frequency (per week) of intense physical exertion (Ptrend = 0.01).
The results demonstrate that while sexual activity can trigger MI, albeit at low risk, regular exercise can reduce or even eliminate this small, transient, increased risk of MI in patients with CHD.

6. Levels of risk for a CV event triggered by sexual activity
Content Points:
A consensus panel developed clinical guidelines for the management of patients with CVD and ED. The guidelines consist of a cardiac risk classification system plus a simple algorithm that guides physicians in managing patients in each risk category.52
Low-risk patients are at no significant cardiac risk for sexual activity. Their patient profiles include52:
- Fewer than three of the major CV risk factors, excluding gender
- Well-controlled hypertension
- Mild, stable angina, previously evaluated and effectively treated
- Post-successful coronary revascularization-either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI)
- Past MI >6-8 weeks; currently asymptomatic with no ongoing ischemia and a negative post-MI stress test
- Mild mitral valve disease
- Mild LV dysfunction or CHF, as defined by NYHA class I HF (cardiac disease that permits physical activity without symptoms)

7. Levels of risk for a CV event triggered by sexual activity (cont'd)
Content Points:
Intermediate-risk patients require further testing to evaluate safety in resuming sexual activity. After testing, these patients may be reassigned to the low- or high-risk categories.
Intermediate-risk patients include those who have52:
- Three or more risk factors for CAD, excluding gender, but patients are asymptomatic
- Moderate, stable angina
- Recent MI (>2, <6 weeks)-indicating a slightly higher risk for ischemia, reinfarction, and/or malignant arrhythmia if sexual activity is resumed
- LV dysfunction or CHF defined as NYHA class II HF (patients with slight limitations, eg, walking causes dyspnea)
- Noncardiac sequelae of atherosclerotic disease, such as peripheral vascular disease, stroke, or transient ischemic attacks

8. Levels of risk for a CV event triggered by sexual activity (cont'd)
Content Points:
High-risk patients have a severe and/or unstable cardiac condition such that sexual activity carries a significant risk.
This category consists of patients whose profiles include52:
- Unstable or refractory angina-new onset, severe, occurs at rest, or refractory; functional cardiac reserve is exceeded by mild physical activity, including sexual intercourse
- Uncontrolled hypertension-therefore, at risk for acute cardiac and vascular events, including stroke
- LV dysfunction and CHF defined as NYHA class III or IV HF-indicating CHF with marked limitation and symptoms easily provoked (class III) or breathlessness at rest (class IV)
- Recent MI (<2 weeks)-the period of maximum risk for post-MI cardiac problems that may be caused by sexual activity
- High-risk arrhythmia (however, patients with implanted defibrillators or pacemakers are probably not at greater risk)
- Hypertrophic obstructive cardiomyopathy, or idiopathic hypertrophic subaortic stenosis (relatively rare conditions)
- Moderate or severe valvular disease-in particular, aortic stenosis

9. Suggested algorithm for management of erectile dysfunction in patients at risk for CV events
Content Points:
This slide shows the suggested algorithm for CV risk stratification and patient management.52
Step 1-Clinical evaluation of sexual function of all cardiac patients, which should be routinely included with the initial evaluation.
- Further evaluation should include a medical history, physical exam, and laboratory tests
- Patients are classified as low, intermediate, or high risk. Intermediate-risk patients need further CV testing to be reclassified into the low- or high-risk categories
Step 2-Advise and/or treat low- and high-risk patients.
- Low-risk patients are usually encouraged to initiate or resume sexual activity or be treated for any sexual dysfunction.
- In contrast, high-risk patients should be advised to defer sexual activity or treatment for sexual dysfunction until their cardiac condition has been stabilized by appropriate medical treatment
Patients who receive treatment for sexual dysfunction and/or CV disease should be scheduled for follow-up and reassessment at regular intervals, eg, every 6 months.