How would you assess and treat ?
Erectile Dysfunction in HFrEF patients
Asking private Questions but totally confidential :
1- What’s exact problem do you face inn your intimate relation ship?
2-Since when it started? Sudden onset or Gradual?
3-Do you feel the mind is willing but the body is not?
4-Do you have a problem in sustaining erection?
5-Do you notice Morning Erection?
6-How do you feel inside your self?
Based on the rapid screening, If it occurs sudden onset so mostly it’s Psychological rather than medical cause….
1- Education and counselling about the problem
2- Counselling about the importance to be compliant on HF medications for survival improvement despite the fact that may be some medications may be implicated in Erectile dysfunction (Especially Beta blockerr ) with empathy and sympathy
3-We can selectively prescribe Nebivolol rather than any other Betablocker as it’s known to improve endothelial NO system
3-Prescription of PDi (Sildenafil or Taladafil) would be helpful
4-Correct other Modifiable risk factors for atherosclerosis (Like DM, HTN , Obesity, Hyperlipidemia, Smoking)
5-Check androgen levels to exclude secondary Hypogonadism associated with Cardiac patients and if low replacement would help after Consulting Andrologist.
6-involve Psychiatrist to assess the patient mood because depression also one of important causes of ED in such patients.
Before prescribing sildenafil need to stop nitrates 24 hrs before
And functional status should be evaluated by treadmill test whether patient can achieve 5 -6 mets roughly required to perform intercourse
PDI along with anti hypertensive ( specially nitrate and beta blocker ) cause sever hypotension.. remember that as well
Epleronone would be a good choice
Big heart, big dreams, small expectations!
Firstly, ask the patient about his real sexual life expectations! Then, teach your patient about the real sex life expectations when having to live with HF! The heart may be pumping ok at rest but will be definitely jumping out of his chest with strenuous physical activity! Prepare the patient, help him face his real strengths and possibilities!
Then do some labs.
Very complicated topic especially in diabetics
Their only hope is sildenafil group, for 5 minutes joy, burning in stomach, headache, vision problem for 24 hrs.
They have to take 3 to 4 tablets for one sildenafil to overcome the side effects of it.
Frankly speaking yet no safe enjoyfull remedy for erectile dysfunction in diabetics
Exercise gradually , healthy food, control sugar, exercise, exercise.,and exercise
It’s important to mention that:
Nitrate and PDE5 inhibiter interaction in patients with EFrHF on the basis of Ischemia and use Nitrate could cause a severe, potentially fatal drop in blood pressure.
Recommendations for the use of sildenafil in patients with cardiovascular disease:
1) Sildenafil is contraindicated in patients using long- and short-acting nitrates due to the possibility of developing potentially fatal severe hypotension.
2) In patients with stable coronary artery disease treated with long-acting nitrates, one may consider the possibility of suspending the nitrate in accordance with the patient, so that sildenafil can be used.
3) Patients not using long-acting nitrates but requiring nitrates sublingual for treatment of episodes of angina should be informed about the hazarg of using sildenafil, unless the nitrate can be replaced by an alternative medication with no risk of interaction with sildenafil.
4) Any use of nitrate is contraindicated in the 24 hours following the use of sildenafil. Sildenafil is also contraindicated if any nitrate has been used in the preceding 24 hours.
5) High-risk cardiovascular patients, including patients with :
1- atherosclerotic disease
2 – NYHA functional classes II and III
3 – patients individuals above 65 years of age,
4 – hypertensive and
5 – diabetic patients
6 – smokers
7 – patients with moderate to severe dyslipidemia,
8 – and obese individuals,
>>> even if not having asked for sildenafil, should be informed about the potential severe risk of sildenafil-nitrate interaction.
This should be done because patients may obtain sildenafil by other means without the recommendations necessary for its use.
6) High-risk cardiovascular patients should be previously assessed through a treadmill stress test.
The risk of ischemia during coitus is low if they do not develop clinical or electrocardiographic signs, of ischemia and or arrhythmia, until a load of 5 to 6 METs is reached.
These load limits are valid for coitus with the usual partner, in a familiar environment, and without additional overload of excessive consumption of food and alcoholic beverages.
Patients without sexual activity for a long period should be advised to moderate their physical activity and anxiety during their return to sexual activity.
7) In patients without ischemia and or arrhythmia, or both, on the treadmill stress test with load lower than 5 to 6 METs, the use of sildenafil should be conditioned to the clinical situation of the patient.
8) It is convenient that patients using vasodilators and diuretics simultaneously should be monitored for a hypotensive response to sildenafil.
9) Physicians and allied health personal emergency departments should be instructed to routinely ask patients about the use of sildenafil.
10) Patients using sildenafil should be instructed to tell about the use of sildenafil in case of an emergency.
11) An initial dose of 25 mg should be recommended in all situations that may increase the plasma concentration of sildenafil or potentiate its vasodilating effect and that do not constitute a formal contraindication for its use.
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