Abstract
Purpose of Review
Heart failure (HF) and erectile dysfunction (ED) are two common conditions that affect millions of men worldwide and impair their quality of life. ED is a frequent complication of HF, as well as a possible predictor of cardiovascular events and mortality. ED deserves more attention from clinicians and researchers.
Recent Findings
The pathophysiology of ED in HF involves multiple factors, such as endothelial dysfunction, reduced cardiac output, neurohormonal activation, autonomic imbalance, oxidative stress, inflammation, and drug side effects. The diagnosis of ED in HF patients should be based on validated questionnaires or objective tests, as part of the routine cardiovascular risk assessment. The therapeutic management of ED in HF patients should be individualized and multidisciplinary, considering the patient’s preferences, expectations, comorbidities, and potential drug interactions. The first-line pharmacological treatment for ED in HF patients with mild to moderate symptoms (NYHA class I–II) is phosphodiesterase type 5 inhibitors (PDE5Is), which improve both sexual function and cardiopulmonary parameters. PDE5Is are contraindicated in patients who use nitrates or nitric oxide donors for angina relief, and these patients should be advised to avoid sexual activity or to use alternative treatments for ED. Non-pharmacological treatments for ED, such as psychotherapy or couples therapy, should also be considered if there are significant psychosocial factors affecting the patient’s sexual function or relationship.
Summary
This review aims to summarize the most recent evidence regarding the prevalence of ED, the pathophysiology of this condition with an exhaustive analysis of factors involved in ED development in HF patients, a thorough discussion on diagnosis and management of ED in HF patients, providing practical recommendations for clinicians.
Similar content being viewed by others
Introduction
Heart failure (HF) is a chronic condition characterized by the inability of the heart to pump enough blood to meet the metabolic demands of the body [1]. HF affects more than 26 million people worldwide and is associated with high morbidity and mortality [2,3,4]. HF can cause various symptoms and complications that reduce the quality of life of patients and their partners, such as dyspnea, fatigue, edema, arrhythmias, depression, and sexual dysfunction [1].
Erectile dysfunction (ED) is defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual activity [5]. This condition affects more than 150 million men worldwide and its prevalence increases with age [5]. ED can have a negative impact on the psychological and emotional well-being of patients and their partners, as well as on their adherence to medical treatment [6]. Moreover, it can be also a marker of underlying cardiovascular disease (CVD), as it may precede the onset of HF symptoms by several years [7].
ED is a common complication of HF, affecting up to 81% of these patients [1]. The association between these two conditions is bidirectional and complex, involving multiple factors that impair the normal erectile function [7]. Moreover, the treatment of ED in HF patients poses several challenges and requires careful evaluation and individualization [1]. Therefore, it is important for clinicians to understand the causes, prevalence, diagnosis, and management of ED in HF patients, as well as the potential implications for their cardiovascular risk and prognosis.
This review aims to provide an updated overview of the current evidence and clinical implications regarding ED in HF patients.
Prevalence of ED in HF
The prevalence of ED in HF patients is vastly increased, compared to the general population or patients with other cardiac diseases. ED is a common and distressing complication of HF that affects the quality of life and prognosis of these patients. It can be a marker of underlying cardiovascular disease and it can precede the onset of HF symptoms by several years [8].
The prevalence of ED in the general population is estimated to range from 2% in men younger than 40 years to 86% in men 80 years and older [9]. However, among HF patients, the prevalence of ED is much higher, with reports ranging between 74 and 84% [10,11,12].
The prevalence of ED in HF patients may vary according to several factors, such as the definition and measurement of ED, the severity and etiology of HF, the age and comorbidities of the patients, and the use of medications that may affect erectile function. However, it is clear that ED is a frequent and distressing complication of HF that affects the majority of these patients. Several studies have reported a correlation between the severity of HF and the severity of ED. For example, a study by Apostolo et al. found that none of the patients with peak oxygen consumption (VO2) < 10 mL/min/kg had normal or slightly impaired sexual function, while 34% of those with peak VO2 between 10 and 14 mL/min/kg had normal or slightly reduced sexual performance [13]. It revealed, also, a clear association between the New York Heart Association (NYHA) classification and both the prevalence and severity of ED, as measured by the International Index of Erectile Function (IIEF). In particular, the percentage of patients with normal or mildly impaired erectile function decreased from 70 to 50%, 10%, and almost 0% in patients with NYHA classifications of I, II, and IV, respectively [13]. Furthermore, within the same study, an in-depth analysis was conducted to evaluate the interaction between ED and other comorbidities. The results of this multivariate analysis revealed that, among the various comorbidities considered, only anemia and diabetes emerged as the comorbidities most frequently associated with ED [13]. Another study by Baumhäkel and Böhm found that patients with moderate or severe impairment of left ventricular ejection fraction (LVEF) had a significant increase of ED, thus identifying reduced LVEF as an independent risk factor for the development of ED in cardiovascular high-risk patients [14]. However, most of these studies have not showed adequate attention to the assessment of sexual function in patients with HF and preserved ejection fraction (HFpEF) and those with mid-range ejection fraction (HFmrEF), primarily focusing on patients with HF and reduced ejection fraction (HFrEF) [15]. This underscores the need for a comprehensive investigation into potential differences in sexual function among these distinct phenotypes within the HF spectrum. Such research could offer valuable insights into the relationship between LVEF and sexual function, shed light on alternative mechanisms, and potentially lead to different approaches in counseling and treatment [15].
All these findings suggest that the degree of impairment in cardiac function, exercise capacity, and the presence of comorbidities such as anemia and diabetes may influence the degree of impairment in erectile function. Therefore, assessing the severity of ED in HF patients may provide useful information about their cardiovascular risk, prognosis, and the potential impact of these comorbidities.
Pathophysiology of ED in HF
The normal erectile function depends on a complex interaction between vascular, neural, hormonal, and psychological factors [5]. The main physiological mechanism involved in erection is the relaxation of the cavernosal smooth muscle cells (CSMCs), which allows the inflow of blood into the corpora cavernosa and the compression of the venous outflow [5]. This process is mediated by nitric oxide (NO), which is produced by endothelial cells (ECs) and neuronal cells (nNOS) in response to sexual stimulation. NO activates guanylate cyclase (GC) in CSMCs, which converts guanosine triphosphate (GTP) into cyclic guanosine monophosphate (cGMP) [5, 7]. cGMP then activates protein kinase G (PKG), which phosphorylates various proteins that regulate calcium homeostasis and contractility in CSMCs [5, 7]. The result is a decrease in intracellular calcium concentration and a relaxation of CSMCs. The cGMP is degraded by phosphodiesterase type 5 (PDE5), which is expressed in CSMCs and other tissues [5, 7]. The balance between NO production and cGMP degradation determines the duration and intensity of the erection.
The pathophysiology of ED in HF is complex and multifactorial, involving both organic and psychosocial factors [5, 16]. The main organic factors are endothelial dysfunction, reduced cardiac output, neurohormonal activation, autonomic imbalance, oxidative stress, inflammation, and drug side effects [5, 16]. The factors involved are summarized in Fig. 1.
The physiopathology of erectile dysfunction in heart failure patients is complex and multifactorial. Several organic factors may lead to its development. A detailed description of each factor is provided in the text.
Endothelial Dysfunction
Endothelial dysfunction is a key mechanism that impairs the vasodilation of the penile arteries and the relaxation of the CSMCs, leading to impaired erectile function [16]. It is characterized by a reduced bioavailability of NO, due to decreased synthesis, increased degradation, or impaired signaling [16]. Endothelial dysfunction can be caused by various factors, such as aging, hypertension, diabetes, dyslipidemia, smoking, obesity, inflammation, and oxidative stress [17, 18]. Endothelial dysfunction is also a hallmark of HF, as it contributes to the progression of atherosclerosis, the development of cardiac remodeling, and the activation of neurohormonal systems [17, 18]. Therefore, HF patients have a double burden of endothelial dysfunction, affecting both the systemic and the penile circulation [17, 18].
Several studies have shown that HF patients have reduced endothelium-dependent vasodilation in the brachial artery and in the cavernosal artery, compared to healthy controls or patients with coronary artery disease [17]. Moreover, HF patients have lower levels of circulating NO metabolites and higher levels of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of NO synthase (NOS) [19]. These findings indicate that HF patients have impaired NO production and/or signaling in the penile endothelium, which may explain their reduced erectile function [19].
Reduced Cardiac Output
Reduced cardiac output is another factor that can affect the blood flow to the penis and the oxygen delivery to the erectile tissue. HF patients have lower resting and peak cardiac output than healthy controls [20]. Moreover, HF patients have impaired chronotropic and inotropic responses to exercise or sexual activity [21], which limit their ability to increase their cardiac output when needed. Therefore, HF patients may have insufficient blood flow and oxygen supply to the penis during sexual stimulation, resulting in impaired erection.
Several studies have shown that HF patients have lower penile blood flow at baseline and during pharmacological or visual stimulation than healthy controls [22, 23]. HF patients have impaired penile hemodynamics and oxygenation, leading to ED.
Neurohormonal Activation
Neurohormonal activation controls vascular and neural pathways involved in erectile function. HF patients have increased levels of several neurohormones, such as norepinephrine, angiotensin II, aldosterone, endothelin-1, and vasopressin [24]. These neurohormones can have deleterious effects on the cardiovascular system, such as vasoconstriction, sodium retention, cardiac hypertrophy, and fibrosis. Moreover, they can also interfere with the erectile function by reducing NO bioavailability, increasing oxidative stress and inflammation, impairing endothelial function and smooth muscle relaxation, altering autonomic balance, and modulating central nervous system activity [25].
Higher plasma levels of norepinephrine, angiotensin II, aldosterone, and endothelin-1 were detected in HF patient as compared to healthy controls [26].
Autonomic Imbalance
Autonomic imbalance can affect the neural pathways involved in erectile function. The normal erectile function depends on a balance between sympathetic and parasympathetic nervous system activity [27]. The parasympathetic nervous system mediates the initiation of erection by releasing NO from nNOS in response to sexual stimulation. The sympathetic nervous system mediates the maintenance of erection by releasing norepinephrine from adrenergic nerves, which stimulates alpha-adrenergic receptors on CSMCs and causes their contraction. The sympathetic nervous system also mediates the ejaculation and detumescence by releasing norepinephrine from adrenergic nerves, which stimulates alpha-adrenergic receptors on the bulbocavernosus and ischiocavernosus muscles and causes their contraction [28]. Autonomic imbalance can alter the balance between sympathetic and parasympathetic nervous system activity, which is essential for initiating and maintaining an erection [29].
HF patients have increased sympathetic activation and decreased parasympathetic activation, resulting in autonomic imbalance [30]. Moreover, they have higher plasma levels of norepinephrine and lower levels of heart rate variability than healthy controls [31]. These findings indicate that HF patients have increased sympathetic tone and reduced parasympathetic tone, inducing ED.
Oxidative Stress
Oxidative stress is a state of imbalance between the production of reactive oxygen species (ROS) and the antioxidant defense mechanisms. ROS are molecules that contain oxygen and have high reactivity, such as superoxide anion (O2–), hydrogen peroxide (H2O2), and hydroxyl radical (OH–). ROS can cause oxidative damage to various biomolecules, such as lipids, proteins, and DNA, impairing their structure and function [32, 33]. ROS can also modulate the activity of various enzymes and signaling molecules, such as NOS, GC, PKG, and PDE5, affecting their regulation of erectile function [34].
HF patients have increased oxidative stress, due to increased production of ROS and decreased antioxidant capacity [35]. Higher levels of oxidative stress markers, such as malondialdehyde (MDA), 8-hydroxy-2′-deoxyguanosine (8-OHdG), and nitrotyrosine (NT), were observed in these patients as compared healthy controls [36]. To summarize, HF patients have increased oxidative damage and reduced antioxidant defense, which may impair their erectile function.
Inflammation
Inflammation plays a central role in ED. It represents a complex biological response to tissue injury or infection, involving various cells, mediators, and pathways. Inflammation can cause vasodilation, increased vascular permeability, leukocyte infiltration, cytokine release, and tissue damage [37, 38]. In addition, it can also modulate the activity of various enzymes and signaling molecules, such as NOS, GC, PKG, and PDE5, affecting their regulation of erectile function [39]. HF patients have increased inflammation, due to a marked activation of immune cells and cytokines, with higher levels of inflammatory markers, such as C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and monocyte chemoattractant protein-1 (MCP-1), than healthy controls [40]. HF patients have increased inflammatory response and tissue damage, which may promote ED.
Drug Side Effects
Several drugs recommended in the treatment of HF can interfere with the hormonal, vascular, and neural pathways involved in erectile function. Therefore, these drugs should be used at the lowest effective doses and monitored for their effects on sexual function. If possible, alternative drugs with less or no impact on sexual function should be considered.
The main classes of drugs that can induce ED in HF patients are diuretics, beta-blockers, and spironolactone [25] (Table 1). Diuretics are drugs that increase the excretion of water and electrolytes by the kidneys, reducing the blood volume and the preload of the heart. These drugs are essential for the treatment of HF patients with fluid retention and edema [41]. However, diuretics can also affect the erectile function by causing hypovolemia, hypotension, electrolyte imbalance, dehydration, and activation of the renin–angiotensin–aldosterone system (RAAS) [42]. They can reduce the production of testosterone and increase the production of prolactin, affecting the hormonal regulation of sexual function [43]. The main types of diuretics involved are thiazide and loop diuretics. Beta-blockers are drugs that block the beta-adrenergic receptors on various tissues, reducing the effects of sympathetic stimulation. These drugs are essential for the treatment of patients with HFrEF (class I recommendation according to the latest European guidelines [44]), as they reduce the heart rate, blood pressure, myocardial oxygen consumption, and cardiac remodeling. However, beta-blockers may induce ED by reducing the cardiac output, blood flow, and oxygen delivery to the penis [45]. Beta-blockers can also impair the neural regulation of sexual function by blocking the beta-adrenergic receptors on the penile smooth muscle and nerves [46]. The main types of beta-blockers that can affect erectile function are nonselective beta-blockers and beta-1 selective blockers. Spironolactone is a mineralocorticoid receptor antagonist acting on various tissues, reducing the effects of aldosterone. It shares the same remodeling effects as beta-blockers [47]. Relevant side effects are hyperkalemia, gynecomastia, impotence, and decreased libido [48]. Spironolactone can also interfere with the hormonal regulation of sexual function by inhibiting the synthesis of testosterone and enhancing the conversion of testosterone to estradiol [49].
Several drugs recommended in the therapeutic management of heart failure may cause erectile dysfunction. The development of this side effect is related to several mechanisms. When prescribing these drugs, erectile dysfunction should be prompt recognized as side effect and the molecules implicated should be down titrated at the lowest effective doses or replaced with a molecule of the same class having a less or no impact on sexual function.
Diagnosis of ED in HF
The diagnosis of ED in HF patients is a crucial step to identify and treat this common and distressing condition, as well as to assess the cardiovascular risk and prognosis of these patients. The diagnosis should be based on a comprehensive and multidisciplinary approach, involving clinical history, physical examination, validated questionnaires, and objective tests as shown in Fig. 2 [16].
The clinical history represents the first and most important step in the diagnosis of ED in HF patients. It should include questions about the onset, duration, frequency, severity, and causes of ED, as well as its impact on the patient’s quality of life, relationship, and sexual satisfaction. It should also include questions about the patient’s sexual history, preferences, expectations, and goals, as well as any psychosocial factors that may affect his sexual function or motivation. The patient’s medical history should be investigated, especially regarding any comorbidities or medications that may cause or contribute to ED [50]. The clinical history should be conducted in a respectful and empathic manner, using clear and non-judgmental language.
The physical examination is the second step in the diagnostic evaluation. It should include a general examination to assess the patient’s vital signs, body mass index (BMI), cardiovascular status, and signs of low testosterone (such as gynecomastia, reduced body hair, or muscle mass) [51].
Validated questionnaires are useful tools to quantify the degree and severity of ED, as well as to monitor its response to treatment. The most widely used questionnaire for ED is the International Index of Erectile Function-5 (IIEF-5), which consists of 15 questions that assess the patient’s erectile function during the past 4 weeks [52]. The IIEF-5 score ranges from 5 to 25, with lower scores indicating more severe ED. The IIEF-5 score can be classified into five categories: no ED (22–25), mild ED (17–21), mild to moderate ED (12–16), moderate ED (8–11), and severe ED (5–7) [53]. The IIEF-5 questionnaire has been validated in various languages and populations, including HF patients [54].
Objective tests are the last step in the diagnosis of ED in HF patients. They are used to confirm the diagnosis of ED, to identify its etiology, and to exclude any organic causes. The most widely used objective tests for ED are:
-
Nocturnal penile tumescence (NPT) test: it measures the frequency and duration of spontaneous erections during sleep using a device attached to the penis. A normal NPT test indicates that there is no organic cause for ED and that it is mainly psychogenic. An abnormal NPT test indicates that there is an organic cause for ED and that it may be vascular or neurogenic [55].
-
Penile Doppler ultrasound: the blood flow within the penile arteries before and after an intracavernosal injection of a vasoactive agent (such as prostaglandin E1 or papaverine) was assessed with this technique. A normal penile Doppler ultrasound shows an increase in peak systolic velocity (> 30 cm/s) and a decrease in end-diastolic velocity (< 5 cm/s) after injection, indicating adequate arterial inflow and venous outflow. An abnormal penile Doppler ultrasound shows a decrease or no change in peak systolic velocity (< 30 cm/s) or an increase or no change in end-diastolic velocity (> 5 cm/s) after injection, indicating arterial insufficiency or venous leakage [56,57,58,59].
-
Penile dynamic infusion cavernosometry and cavernosography: these tests measure the intracavernosal pressure and volume before and after an intracavernosal injection of a vasoactive agent (such as prostaglandin E1 or papaverine), while simultaneously injecting saline into the corpora cavernosa under fluoroscopic guidance. A normal penile dynamic infusion cavernosometry shows a rapid increase in intracavernosal pressure after injection, indicating adequate arterial inflow. A normal penile dynamic infusion cavernosography shows a smooth and symmetrical filling of the corpora cavernosa without any leakage or extravasation of contrast, indicating adequate venous outflow. An abnormal penile dynamic infusion cavernosometry shows a slow or no increase in intracavernosal pressure after injection, indicating arterial insufficiency. An abnormal penile dynamic infusion cavernosography shows an irregular or asymmetrical filling of the corpora cavernosa with leakage or extravasation of contrast, indicating venous leakage [60,61,62].
-
Penile biothesiometry: this test measures the vibratory threshold of the penile skin using a biothesiometer, which is a device that delivers variable frequencies of vibration to the glans and shaft of the penis. It is based on the principle that the threshold of vibration detection is related to the integrity of the nerve fibers that innervate the penis. Penile biothesiometry can be used to diagnose penile neuropathy, which is a common cause of ED, especially in patients with diabetes, Peyronie’s disease, or spinal cord injury. Penile biothesiometry can also be used to assess changes in penile sensitivity after penile reconstructive procedures that may compromise penile sensation [63]. A novel parameter that can be derived from penile biothesiometry is the penile sensitivity ratio (PSR), which is calculated by dividing the vibratory threshold of the penile glans or shaft by the vibratory threshold of the index finger or thigh. The PSR is inversely correlated with penile sensitivity, meaning that a higher PSR indicates a lower sensitivity. The PSR can help identify patients with diminished penile sensitivity and evaluate the association between penile sensitivity and various factors such as age, diabetes, ejaculatory dysfunction, and Peyronie’s disease [64].
The choice of objective tests for ED in HF patients depends on the local availability of the equipment, the expertise of the operator, the preference of the patient, and the suspected etiology of ED. In general, penile Doppler ultrasound is the most widely used and recommended objective test for ED in HF patients, as it is noninvasive, reliable, reproducible, and informative [58]. Penile dynamic infusion cavernosometry and cavernosography are more invasive, expensive, and time-consuming tests that are reserved for patients with suspected venous leakage who are candidates for surgical treatment [65]. Penile biothesiometry is a simple and inexpensive test that can be used as an adjunct to other tests to assess the neurogenic component of ED [66].
Therapeutic Management of ED in HF
The therapeutic management of ED in HF patients should be individualized and multidisciplinary, taking into account the patient’s preferences, expectations, comorbidities, and potential drug interactions. The main goals are the improvement of the sexual function and quality of life of the patient and his partner, the optimization the HF treatment, and the modification of any lifestyle or behavioral factors that may contribute to ED. The management of ED in HF patients involves four areas: optimization of HF treatment, lifestyle modification, pharmacological treatment with PDE5Is or other agents, and non-pharmacological treatment with psychotherapy or couples therapy. This approach is summarized in Fig. 2.
Optimization of HF Treatment and Lifestyle Modification
The optimization of HF treatment and any lifestyle or behavioral changes play a key role in the therapeutic approach. Beneficial effects are evident not only on the erectile function but also on the cardiovascular performance and prognosis of the patient [67]. Optimization of HF treatment involves adjusting the doses and combinations of drugs according to the current guidelines and the patient’s clinical status. Some drugs used to treat HF, such as diuretics, beta-blockers, and spironolactone, can interfere with the hormonal, vascular, and neural pathways involved in erectile function [51]. Therefore, these drugs should be used at the lowest effective doses and monitored for their effects on sexual function. If possible, alternative drugs with less or no impact on sexual function should be considered, such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), nitrates, or nebivolol [68,69,70].
Lifestyle modification is based upon the removal of any modifiable risk factors for ED and CVD, such as smoking habit, obesity, sedentary behavior, and stressful lifestyle. Smoking habit is a major risk factor for ED and CVD, as it causes endothelial dysfunction, oxidative stress, and inflammation [71]. Smoking cessation can improve both erectile function and cardiovascular function in HF patients [72]. Weight loss may induce beneficial effects on both erectile and cardiovascular function in obese HF patients by reducing insulin resistance, inflammation, and oxidative stress [73]. Physical activity can improve both erectile function and cardiovascular function in HF patients by enhancing endothelial function, increasing NO bioavailability, reducing oxidative stress and inflammation, improving autonomic balance, and modulating central nervous system activity [74, 75]. Stress management may have a positive role in ED, reducing sympathetic activation, cortisol levels, oxidative stress, and inflammation [76, 77].
Pharmacological Treatment With PDE5Is or Other Agents
The second area in the management of ED in HF patients is the prescription of a pharmacological treatment with PDE5Is or other agents. This approach improves the sexual function and quality of life of the patient and his partner. PDE5Is are the first-line pharmacological treatment for ED in HF patients with mild to moderate symptoms (NYHA class I–II) [78, 79]. PDE5Is enhance the effect of NO on the penile vasculature and smooth muscle, improving erectile function [80]. Several studies have shown that PDE5Is are safe and effective in HF patients with mild to moderate symptoms (NYHA class I–II), as they improve not only their sexual function but also their cardiopulmonary parameters and quality of life [79]. PDE5Is have also beneficial effects on endothelial function, NO bioavailability, oxidative stress, inflammation, and cardiac remodeling in animal models of HF [81]. However, PDE5Is are contraindicated in patients who use nitrates or nitric oxide donors for angina relief, as they can cause severe hypotension and potentially fatal outcomes [82]. Therefore, these patients should be advised to avoid sexual activity or to use alternative treatments for ED.
Other pharmacological agents that can be used for ED in HF patients are alprostadil, testosterone, or yohimbine. Alprostadil is a synthetic prostaglandin E1 that induces vasodilation and smooth muscle relaxation in the penis. It can be administered as an intracavernosal injection or an intraurethral pellet [83]. Alprostadil is effective for ED regardless of its etiology, but it has some drawbacks such as pain at the injection site or urethral irritation [84]. Testosterone is the main male sex hormone that regulates sexual function and libido. It can be administered as an intramuscular injection, a transdermal patch, or a gel [85]. Testosterone can improve erectile function and sexual desire in hypogonadal HF patients, but it has some risks such as prostate enlargement, polycythemia, and cardiovascular events [86]. Yohimbine is an alpha-2 adrenergic receptor antagonist that enhances the release of norepinephrine from adrenergic nerves, stimulating erectile function. It can be administered as an oral tablet [87], improving erectile function and sexual satisfaction in HF patients, but it has some side effects such as anxiety, hypertension, and tachycardia [88].
Non-pharmacological Treatment With Psychotherapy or Couples Therapy
Non-pharmacological treatment with psychotherapy or couples therapy has an important role, especially if there are significant psychosocial factors affecting the patient’s sexual function or relationship. Psychotherapy is a form of psychological intervention that aims to help the patient cope with his emotional and cognitive aspects of ED, such as anxiety, depression, low self-esteem, guilt, or shame. Main goals are the identification and correction of any negative thoughts or beliefs that may interfere with his sexual function or satisfaction [6]. Psychotherapy can be delivered individually or in group sessions, using various techniques such as cognitive-behavioral therapy (CBT), mindfulness-based therapy, or hypnotherapy [89,90,91]. Couples therapy is a form of psychological intervention that aims to support the patient and his partner communicate better about their sexual concerns and expectations, enhance their intimacy and trust, and resolve any conflicts or issues that may affect their sexual function or satisfaction. It can also help the partner cope with his or her own emotional reactions to the patient’s ED, such as frustration, anger, resentment, or rejection [92]. Couples therapy can be delivered in conjoint or separate sessions, using various techniques such as sensate focus exercises, sexual education, or homework assignments [93].
Indications for Sexual Activity in HF
The indications for sexual activity in HF patients depend on the severity of their symptoms, their functional capacity, and their cardiovascular risk. Sexual activity can be considered as a form of physical exercise that imposes a certain degree of cardiac stress and oxygen demand. Therefore, it can be safe for HF patients who have mild to moderate symptoms (NYHA class I–II), a good functional capacity, and a low cardiovascular risk (no history of angina, arrhythmias, syncope, or HF exacerbation) [94, 95]. On the other hand, sexual activity can be risky for HF patients with severe symptoms (NYHA class III–IV), a poor functional capacity, and a high cardiovascular risk [96].
HF patients who are not eligible for sexual activity should be counseled about the risks and benefits of sexual activity, the alternative treatments for ED, and the non-coital forms of sexual expression [97]. They should also be referred to a cardiologist for further evaluation and optimization of their HF treatment.
The figure summarizes the management of erectile dysfunction in heart failure patients. The diagnostic algorithm is based on clinical history and physical examination. Subsequently, validated questionnaires are required to confirm the diagnosis. A more objective evaluation of erectile performance may be required in selected cases with specific tests and techniques. The therapeutic management is multidisciplinary and should involve four areas to obtain an improvement on the sexual function and the quality of life of patients. Beneficial effects may be also observed on the cardiovascular performance and prognosis.
Conclusions
ED is a common and distressing complication of HF that deserves more attention from clinicians and researchers. This condition can affect the quality of life and prognosis of HF patients and can also be a sign of underlying CVD. Therefore, screening for ED should be part of the routine evaluation of HF patients and its management should be individualized and multidisciplinary. PDE5Is are the first-line pharmacological treatment in HF patients with mild to moderate symptoms (NYHA class I–II), as they improve their sexual function, cardiopulmonary parameters, and quality of life. However, PDE5Is are contraindicated in patients treated with nitrates or nitric oxide donors for angina relief, and these patients should be advised to avoid sexual activity or to use alternative treatments for ED. Non-pharmacological treatments for ED, such as psychotherapy or couples therapy, should also be considered if there are significant psychosocial factors affecting the patient’s sexual function or relationship.
Data Availability
No new data were created for this review.
References
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Bohm M, Burri H, Butler J, Celutkiene J, Chioncel O, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42:3599–726. https://doi.org/10.1093/eurheartj/ehab368.
Guaricci AI, Masci PG, Muscogiuri G, Guglielmo M, Baggiano A, Fusini L, Lorenzoni V, Martini C, Andreini D, Pavon AG, et al. Cardiac magnetic resonance for prophylactic implantable-cardioverter defibrillator therapy in non-ischaemic dilated cardiomyopathy: an international registry. Europace. 2021;23:1072–83. https://doi.org/10.1093/europace/euaa401.
Pontone G, Guaricci AI, Fusini L, Baggiano A, Guglielmo M, Muscogiuri G, Volpe A, Abete R, Aquaro G, Barison A, et al. Cardiac magnetic resonance for prophylactic implantable-cardioverter defibrillator therapy in ischemic cardiomyopathy: the DERIVATE-ICM international registry. JACC Cardiovasc Imaging. 2023. https://doi.org/10.1016/j.jcmg.2023.03.015.
Chan DZL, Kerr AJ, Doughty RN. Temporal trends in the burden of heart failure. Intern Med J. 2021;51:1212–8. https://doi.org/10.1111/imj.15253.
Hatzimouratidis K, Amar E, Eardley I, Giuliano F, Hatzichristou D, Montorsi F, Vardi Y, Wespes E, European Association of Urology. Guidelines on male sexual dysfunction: erectile dysfunction and premature ejaculation. Eur Urol. 2010;57:804–14. https://doi.org/10.1016/j.eururo.2010.02.020.
Dewitte M, Bettocchi C, Carvalho J, Corona G, Flink I, Limoncin E, Pascoal P, Reisman Y, Van Lankveld J. A psychosocial approach to erectile dysfunction: position statements from the European Society of Sexual Medicine (ESSM). Sex Med. 2021;9:100434. https://doi.org/10.1016/j.esxm.2021.100434.
Baumhakel M, Schlimmer N, Kratz M, Hackett G, Jackson G, Bohm M. Cardiovascular risk, drugs and erectile function—a systematic analysis. Int J Clin Pract. 2011;65:289–98. https://doi.org/10.1111/j.1742-1241.2010.02563.x.
Alberti L, Torlasco C, Lauretta L, Loffi M, Maranta F, Salonia A, Margonato A, Montorsi F, Fragasso G. Erectile dysfunction in heart failure patients: a critical reappraisal. 2013;1:177-191.https://doi.org/10.1111/j.2047-2927.2012.00048.x.
Prins J, Blanker MH, Bohnen AM, Thomas S, Bosch JL. Prevalence of erectile dysfunction: a systematic review of population-based studies. Int J Impot Res. 2002;14:422–32. https://doi.org/10.1038/sj.ijir.3900905.
Medina M, Walker C, Steinke EE, Wright DW, Mosack V, Farhoud MH. Sexual concerns and sexual counseling in heart failure. Prog Cardiovasc Nurs. 2009;24:141–8. https://doi.org/10.1111/j.1751-7117.2009.00052.x.
Schwarz ER, Kapur V, Bionat S, Rastogi S, Gupta R, Rosanio S. The prevalence and clinical relevance of sexual dysfunction in women and men with chronic heart failure. Int J Impot Res. 2008;20:85–91. https://doi.org/10.1038/sj.ijir.3901613.
Rastogi S, Rodriguez JJ, Kapur V, Schwarz ER. Why do patients with heart failure suffer from erectile dysfunction? A critical review and suggestions on how to approach this problem. Int J Impot Res. 2005;17(Suppl 1):S25-36. https://doi.org/10.1038/sj.ijir.3901426.
Apostolo A, Vignati C, Brusoni D, Cattadori G, Contini M, Veglia F, Magrì D, Palermo P, Tedesco C, Doria E, et al. Erectile dysfunction in heart failure: correlation with severity, exercise performance, comorbidities, and heart failure treatment. J Sex Med. 2009;6:2795–805. https://doi.org/10.1111/j.1743-6109.2009.01416.x.
Baumhäkel M, Böhm M. Erectile dysfunction correlates with left ventricular function and precedes cardiovascular events in cardiovascular high-risk patients. Int J Clin Pract. 2007;61:361–6. https://doi.org/10.1111/j.1742-1241.2006.01274.x.
Koutsampasopoulos K, Ziakas A, Vogiatzis I. Sexual function of patients with heart failure: distinct phenotypes, distinct sexual function? ESC heart failure. 2017;4:319. https://doi.org/10.1002/ehf2.12182.
Giagulli VA, Moghetti P, Kaufman JM, Guastamacchia E, Iacoviello M, Triggiani V. Managing erectile dysfunction in heart failure. Endocr Metab Immune Disord Drug Targets. 2013;13:125–34. https://doi.org/10.2174/1871530311313010015.
Montorsi P, Ravagnani PM, Galli S, Rotatori F, Veglia F, Briganti A, Salonia A, Deho F, Rigatti P, Montorsi F, et al. Association between erectile dysfunction and coronary artery disease. Role of coronary clinical presentation and extent of coronary vessels involvement: the COBRA trial. Eur Heart J. 2006;27:2632–9. https://doi.org/10.1093/eurheartj/ehl142.
Vlachopoulos C, Rokkas K, Ioakeimidis N, Stefanadis C. Inflammation, metabolic syndrome, erectile dysfunction, and coronary artery disease: common links. Eur Urol. 2007;52:1590–600. https://doi.org/10.1016/j.eururo.2007.08.004.
Baldassarri F, Schwedhelm E, Atzler D, Boger RH, Cordts K, Haller B, Pressler A, Muller S, Suchy C, Wachter R, et al. Relationship between exercise intervention and NO pathway in patients with heart failure with preserved ejection fraction. Biomarkers. 2018;23:540–50. https://doi.org/10.1080/1354750X.2018.1460762.
Brochhagen J, Coll Barroso MT, Baumgart C, Freiwald J, Hoppe MW. Non-invasively measured central and peripheral factors of oxygen uptake differ between patients with chronic heart failure and healthy controls. BMC Cardiovasc Disord. 2020;20:378. https://doi.org/10.1186/s12872-020-01661-4.
Colucci WS, Ribeiro JP, Rocco MB, Quigg RJ, Creager MA, Marsh JD, Gauthier DF, Hartley LH. Impaired chronotropic response to exercise in patients with congestive heart failure. Role of postsynaptic beta-adrenergic desensitization. Circulation. 1989;80:314–23. https://doi.org/10.1161/01.cir.80.2.314.
Zeighami Mohammadi S, Shahparian M, Fahidy F, Fallah E. Sexual dysfunction in males with systolic heart failure and associated factors. ARYA Atherosclerosis. 2012;8:63–9.
Schwartz BG, Kloner RA. Cardiovascular implications of erectile dysfunction. Circulation. 2011;123:e609–11. https://doi.org/10.1161/CIRCULATIONAHA.110.017681.
Hartupee J, Mann DL. Neurohormonal activation in heart failure with reduced ejection fraction. Nat Rev Cardiol. 2017;14:30–8. https://doi.org/10.1038/nrcardio.2016.163.
Schwarz ER, Rastogi S, Kapur V, Sulemanjee N, Rodriguez JJ. Erectile dysfunction in heart failure patients. J Am Coll Cardiol. 2006;48:1111–9. https://doi.org/10.1016/j.jacc.2006.05.052.
Lymperopoulos A, Rengo G, Koch WJ. Adrenergic nervous system in heart failure: pathophysiology and therapy. Circ Res. 2013;113:739–53. https://doi.org/10.1161/circresaha.113.300308.
Dean RC, Lue TF. Physiology of penile erection and pathophysiology of erectile dysfunction. Urol Clin North Am. 2005;32:379–95. https://doi.org/10.1016/j.ucl.2005.08.007.
Azadzoi KM, Yang J, Siroky MB. Neural regulation of sexual function in men. World J Clin Urol. 2013;2:32–41. https://doi.org/10.5410/wjcu.v2.i3.32.
Mathias CJ. Autonomic nervous system disorders and erectile dysfunction. Int J STD AIDS. 1996;7(Suppl 3):5–8. https://doi.org/10.1258/0956462961917997.
Zhang DY, Anderson AS. The sympathetic nervous system and heart failure. Cardiol Clin. 2014;32:33-45.vii. https://doi.org/10.1016/j.ccl.2013.09.010.
Woo MA, Stevenson WG, Moser DK, Middlekauff HR. Complex heart rate variability and serum norepinephrine levels in patients with advanced heart failure. J Am Coll Cardiol. 1994;23:565–9. https://doi.org/10.1016/0735-1097(94)90737-4.
Collin F. Chemical basis of reactive oxygen species reactivity and involvement in neurodegenerative diseases. Int J Mol Sci. 2019;20. https://doi.org/10.3390/ijms20102407.
Guaricci AI, Bulzis G, Pontone G, Scicchitano P, Carbonara R, Rabbat M, De Santis D, Ciccone MM. Current interpretation of myocardial stunning. Trends Cardiovasc Med. 2018;28:263–71. https://doi.org/10.1016/j.tcm.2017.11.005.
Jeremy JY, Jones RA, Koupparis AJ, Hotston M, Persad R, Angelini GD, Shukla N. Reactive oxygen species and erectile dysfunction: possible role of NADPH oxidase. Int J Impot Res. 2007;19:265–80. https://doi.org/10.1038/sj.ijir.3901523.
Senoner T, Dichtl W. Oxidative stress in cardiovascular diseases: still a therapeutic target? Nutrients. 2019;11. https://doi.org/10.3390/nu11092090.
Di Minno A, Turnu L, Porro B, Squellerio I, Cavalca V, Tremoli E, Di Minno MN. 8-Hydroxy-2-deoxyguanosine levels and heart failure: a systematic review and meta-analysis of the literature. Nutr Metab Cardiovasc Dis. 2017;27:201–8. https://doi.org/10.1016/j.numecd.2016.10.009.
Chen L, Deng H, Cui H, Fang J, Zuo Z, Deng J, Li Y, Wang X, Zhao L. Inflammatory responses and inflammation-associated diseases in organs. Oncotarget. 2018;9:7204–18. https://doi.org/10.18632/oncotarget.23208.
Guaricci AI, Pontone G, Fusini L, De Luca M, Cafarelli FP, Guglielmo M, Baggiano A, Beltrama V, Muscogiuri G, Mushtaq S, et al. Additional value of inflammatory biomarkers and carotid artery disease in prediction of significant coronary artery disease as assessed by coronary computed tomography angiography. Eur Heart J Cardiovasc Imaging. 2017;18:1049–56. https://doi.org/10.1093/ehjci/jew173.
Kaya-Sezginer E, Gur S. The inflammation network in the pathogenesis of erectile dysfunction: attractive potential therapeutic targets. Curr Pharm Des. 2020;26:3955–72. https://doi.org/10.2174/1381612826666200424161018.
Reina-Couto M, Pereira-Terra P, Quelhas-Santos J, Silva-Pereira C, Albino-Teixeira A, Sousa T. Inflammation in human heart failure: major mediators and therapeutic targets. Front Physiol. 2021;12:746494. https://doi.org/10.3389/fphys.2021.746494.
Faris RF, Flather M, Purcell H, Poole-Wilson PA, Coats AJ. WITHDRAWN: diuretics for heart failure. Cochrane Database Syst Rev. 2016;4:Cd003838. https://doi.org/10.1002/14651858.CD003838.pub4.
Chang SW, Fine R, Siegel D, Chesney M, Black D, Hulley SB. The impact of diuretic therapy on reported sexual function. Arch Intern Med. 1991;151:2402–8.
Perry HM 3rd, Jensen J, Kaiser FE, Horowitz M, Perry HM Jr, Morley JE. The effects of thiazide diuretics on calcium metabolism in the aged. J Am Geriatr Soc. 1993;41:818–22. https://doi.org/10.1111/j.1532-5415.1993.tb06176.x.
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, et al. 2021 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42:3599–726. https://doi.org/10.1093/eurheartj/ehab368.
Manolis A, Doumas M, Ferri C, Mancia G. Erectile dysfunction and adherence to antihypertensive therapy: focus on β-blockers. Eur J Intern Med. 2020;81:1–6. https://doi.org/10.1016/j.ejim.2020.07.009.
Nicolai MP, Liem SS, Both S, Pelger RC, Putter H, Schalij MJ, Elzevier HW. A review of the positive and negative effects of cardiovascular drugs on sexual function: a proposed table for use in clinical practice. Neth Heart J : Mon J Neth Soc Cardiol Neth Heart Found. 2014;22:11–9. https://doi.org/10.1007/s12471-013-0482-z.
Milliez P, Gomes S, Champ-Rigot L, Callebert J, Samuel JL, Delcayre C. Effects of spironolactone alone and in addition to a β-blocker on myocardial histological and electrical remodeling in chronic severe failing rat hearts. J Cardiovasc Pharmacol. 2012;60:315–21. https://doi.org/10.1097/FJC.0b013e318260e688.
Stripp B, Taylor AA, Bartter FC, Gillette JR, Loriaux DL, Easley R, Menard RH. Effect of spironolactone on sex hormones in man. J Clin Endocrinol Metab. 1975;41:777–81. https://doi.org/10.1210/jcem-41-4-777.
Santen RJ, Kulin HE, Loriaux DL, Friend J. Spironolactone stimulation of gonadotropin secretion in boys with delayed adolescence. J Clin Endocrinol Metab. 1976;43:1386–90. https://doi.org/10.1210/jcem-43-6-1386.
Huri HZ, Ling CF, Razack AH. Drug-related problems in patients with erectile dysfunctions and multiple comorbidities. Ther Clin Risk Manag. 2017;13:407–19. https://doi.org/10.2147/tcrm.S118010.
Yafi FA, Jenkins L, Albersen M, Corona G, Isidori AM, Goldfarb S, Maggi M, Nelson CJ, Parish S, Salonia A, et al. Erectile dysfunction. Nature reviews. Dis Prim. 2016;2:16003. https://doi.org/10.1038/nrdp.2016.3.
Dick B, Brimley S, Tsambarlis P, Hellstrom W. Chapter 6.3 - alcohol and men’s health. In Effects of lifestyle on men’s health. Yafi FA, Yafi NR (Eds). Academic Press: 2019;333–347. https://doi.org/10.1016/B978-0-12-816665-9.00018-4.
Rhoden EL, Telöken C, Sogari PR, Vargas Souto CA. The use of the simplified International Index of Erectile Function (IIEF-5) as a diagnostic tool to study the prevalence of erectile dysfunction. Int J Impot Res. 2002;14:245–50. https://doi.org/10.1038/sj.ijir.3900859.
Gonzáles AI, Sties SW, Wittkopf PG, Mara LS, Ulbrich AZ, Cardoso FL, Carvalho T. Validation of the International Index of Erectile Function (IIFE) for use in Brazil. Arq Bras Cardiol. 2013;101:176–82. https://doi.org/10.5935/abc.20130141.
Pfeiffer RF. Chapter 29 - bladder and sexual function and dysfunction. In: Schapira AHV, Byrne E, DiMauro S, Frackowiak RSJ, Johnson RT, Mizuno Y, Samuels MA, Silberstein SD, Wszolek ZK, editors. Neurology and clinical neuroscience. Philadelphia: Mosby; 2007. p. 362–71.
Patel U, Amin Z, Friedman E, Vale J, Kirby RW, Lees WR. Colour flow and spectral Doppler imaging after papaverine-induced penile erection in 220 impotent men: study of temporal patterns and the importance of repeated sampling, velocity asymmetry and vascular anomalies. Clin Radiol. 1993;48:18–24. https://doi.org/10.1016/S0009-9260(05)80101-1.
Fitzgerald SW, Erickson SJ, Foley WD, Lipchik EO, Lawson TL. Color Doppler sonography in the evaluation of erectile dysfunction: patterns of temporal response to papaverine. AJR Am J Roentgenol. 1991;157:331–6. https://doi.org/10.2214/ajr.157.2.1853817.
Jung DC, Park SY, Lee JY. Penile Doppler ultrasonography revisited. Ultrasonography (Seoul, Korea). 2018;37:16–24. https://doi.org/10.14366/usg.17022.
Varela CG, Yeguas LAM, Rodríguez IC, Vila MDD. Penile Doppler ultrasound for erectile dysfunction: technique and interpretation. AJR Am J Roentgenol. 2020;214:1112–21. https://doi.org/10.2214/ajr.19.22141.
Yanagi S, Suzuki H, Namiki T. [Evaluation of vasculogenic erectile impotence using DICC (dynamic infusion cavernosometry & cevernosography) with intracavernous injection of papaverine]. Nihon Hinyokika Gakkai zasshi. Jpn J Urol. 1993;84:1054–8. https://doi.org/10.5980/jpnjurol1989.84.1054.
Gao QQ, Chen JH, Chen Y, Song T, Dai YT. Dynamic infusion cavernosometry and cavernosography for classifying venous erectile dysfunction and its significance for individual treatment. Chin Med J. 2019;132:405–10. https://doi.org/10.1097/cm9.0000000000000099.
Chen KK, Chen MT, Lo KY, Chang LS. Dynamic infusion cavernosometry and cavernosography (DICC) in the evaluation of vasculogenic impotence. Zhonghua yi xue za zhi = Chin Med J; Free China ed. 1996;57:266–73.
Mulhall JP, Jenkins LC. Biothesiometry. In: Mulhall J, Jenkins L, editors. Atlas of office based andrology procedures. Springer, Cham; 2017. https://doi.org/10.1007/978-3-319-42178-0_2
Wiggins A, Farrell MR, Tsambarlis P, Levine LA. The penile sensitivity ratio: a novel application of biothesiometry to assess changes in penile sensitivity. J Sex Med. 2019;16:447–51. https://doi.org/10.1016/j.jsxm.2019.01.002.
Pang K, Pan D, Xu H, Ma Y, Wang J, Xu P, Wang H, Zang G. Advances in physical diagnosis and treatment of male erectile dysfunction. 2023;13. https://doi.org/10.3389/fphys.2022.1096741.
Bemelmans BLH, Hendrikx LBPM, Koldewijn EL, Lemmens WAJG, Debruyne FMJ, Meuleman EJH. Comparison of biothesiometry and neurourophysiological investigations for the clinical evaluation of patients with erectile dysfunction. J Urol. 1995;153:1483–6. https://doi.org/10.1016/S0022-5347(01)67440-8.
Daniel PA, YlvaTrolle L, Alessandra G, Rino B, Mikael L, Martin JH. Association between treatment for erectile dysfunction and death or cardiovascular outcomes after myocardial infarction. Heart (British Cardiac Society). 2017;103:1264. https://doi.org/10.1136/heartjnl-2016-310746.
Ismail SB, Noor NM, Hussain NHN, Sulaiman Z, Shamsudin MA, Irfan M. Angiotensin receptor blockers for erectile dysfunction in hypertensive men: a brief meta-analysis of randomized control trials. Am J Mens Health. 2019;13:1557988319892735. https://doi.org/10.1177/1557988319892735.
Angulo J, Wright HM, Cuevas P, González-Corrochano R, Fernández A, Cuevas B, La Fuente JM, Gupta S, de Tejada IS. Nebivolol dilates human penile arteries and reverses erectile dysfunction in diabetic rats through enhancement of nitric oxide signaling. J Sex Med. 2010;7:2681–97. https://doi.org/10.1111/j.1743-6109.2010.01710.x.
Girardin F, Berney P, Schulz P. An early report on the role of nitrates in erectile dysfunction. Am J Psychiatry. 2009;166:115–115. https://doi.org/10.1176/appi.ajp.2008.08091326.
Tostes RC, Carneiro FS, Lee AJ, Giachini FR, Leite R, Osawa Y, Webb RC. Cigarette smoking and erectile dysfunction: focus on NO bioavailability and ROS generation. J Sex Med. 2008;5:1284–95. https://doi.org/10.1111/j.1743-6109.2008.00804.x.
Sahin MO, Sen V, Gunduz G, Ucer O. Effect of smoking cessation on sexual functions in men aged 30 to 60 years. Int Braz J Urol : Off J Braz Soc Urol. 2020;46:642–8. https://doi.org/10.1590/s1677-5538.Ibju.2019.0541.
Moon KH, Park SY, Kim YW. Obesity and erectile dysfunction: from bench to clinical implication. World J Men’s Health. 2019;37:138–47. https://doi.org/10.5534/wjmh.180026.
Gerbild H, Larsen CM, Graugaard C, Areskoug Josefsson K. Physical activity to improve erectile function: a systematic review of intervention studies. Sex Med. 2018;6:75–89. https://doi.org/10.1016/j.esxm.2018.02.001.
Duca Y, Calogero AE, Cannarella R, Giacone F, Mongioi LM, Condorelli RA, La Vignera S. Erectile dysfunction, physical activity and physical exercise: recommendations for clinical practice. Andrologia. 2019;51:e13264. https://doi.org/10.1111/and.13264.
Kalaitzidou I, Venetikou MS, Konstadinidis K, Artemiadis AK, Chrousos G, Darviri C. Stress management and erectile dysfunction: a pilot comparative study. Andrologia. 2014;46:698–702. https://doi.org/10.1111/and.12129.
Chinnaiyan KM. Role of stress management for cardiovascular disease prevention. Curr Opin Cardiol. 2019;34:531–5. https://doi.org/10.1097/hco.0000000000000649.
Huang SA, Lie JD. Phosphodiesterase-5 (PDE5) inhibitors in the management of erectile dysfunction. P & T : Peer-reviewed J Formul Manag. 2013;38:407–19.
Al-Ameri H, Kloner RA. Erectile dysfunction and heart failure: the role of phosphodiesterase type 5 inhibitors. Int J Impot Res. 2009;21:149–57. https://doi.org/10.1038/ijir.2009.11.
Fukuhara S, Tsujimura A, Okuda H, Yamamoto K, Takao T, Miyagawa Y, Nonomura N, Okuyama A. Vardenafil and resveratrol synergistically enhance the nitric oxide/cyclic guanosine monophosphate pathway in corpus cavernosal smooth muscle cells and its therapeutic potential for erectile dysfunction in the streptozotocin-induced diabetic rat: preliminary findings. J Sex Med. 2011;8:1061–71. https://doi.org/10.1111/j.1743-6109.2010.02193.x.
Reffelmann T, Kloner RA. Phosphodiesterase 5 inhibitors: are they cardioprotective? Cardiovasc Res. 2009;83:204–12. https://doi.org/10.1093/cvr/cvp170.
Schwartz BG, Kloner RA. Drug interactions with phosphodiesterase-5 inhibitors used for the treatment of erectile dysfunction or pulmonary hypertension. Circulation. 2010;122:88–95. https://doi.org/10.1161/CIRCULATIONAHA.110.944603.
Fortney L. Chapter 63 - erectile dysfunction. In: Integrative medicine (fourth edition), Rakel D, editor. Elsevier: 2018;623–629.e622. https://doi.org/10.1016/B978-0-323-35868-2.00063-3.
Jain A, Iqbal OA. Alprostadil. In StatPearls [Internet]; Treasure Island (FL) StatPearls Publishing, 2023.
Borst SE, Yarrow JF. Injection of testosterone may be safer and more effective than transdermal administration for combating loss of muscle and bone in older men. Am J Physiol-Endocrinol Metab. 2015;308:E1035-1042. https://doi.org/10.1152/ajpendo.00111.2015.
Rizk PJ, Kohn TP, Pastuszak AW, Khera M. Testosterone therapy improves erectile function and libido in hypogonadal men. Curr Opin Urol. 2017;27:511–5. https://doi.org/10.1097/mou.0000000000000442.
Susset JG, Tessier CD, Wincze J, Bansal S, Malhotra C, Schwacha MG. Effect of yohimbine hydrochloride on erectile impotence: a double-blind study. J Urol. 1989;141:1360–3. https://doi.org/10.1016/s0022-5347(17)41308-5.
Wibowo D, Soebadi DM, Soebadi MA. Yohimbine as a treatment for erectile dysfunction: a systematic review and meta-analysis. Turk J Urol. 2021;47:482–8. https://doi.org/10.5152/tud.2021.21206.
Khan S, Amjad A, Rowland D. Potential for long-term benefit of cognitive behavioral therapy as an adjunct treatment for men with erectile dysfunction. J Sex Med. 2019;16:300–6. https://doi.org/10.1016/j.jsxm.2018.12.014.
Bossio JA, Basson R, Driscoll M, Correia S, Brotto LA. Mindfulness-based group therapy for men with situational erectile dysfunction: a mixed-methods feasibility analysis and pilot study. J Sex Med. 2018;15:1478–90. https://doi.org/10.1016/j.jsxm.2018.08.013.
Brown JM, Chaves JF. Hypnosis in the treatment of sexual dysfunction. J Sex Marital Ther. 1980;6:63–74. https://doi.org/10.1080/00926238008404247.
Vaishnav M, Saha G, Mukherji A, Vaishnav P. Principles of marital therapies and behavior therapy of sexual dysfunction. Indian J Psychiatr. 2020;62:S213-s222. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_19_20.
Hawton K. 215Further therapeutic approaches. Sex Ther: Pract Guid. 1985;0. https://doi.org/10.1093/med:psych/9780192614131.003.0014.
Levine GN, Steinke EE, Bakaeen FG, Bozkurt B, Cheitlin MD, Conti JB, Foster E, Jaarsma T, Kloner RA, Lange RA, et al. Sexual activity and cardiovascular disease. Circulation. 2012;125:1058–72. https://doi.org/10.1161/CIR.0b013e3182447787.
Dye CA, Engelstein E, Swearingen S, Murphy J, Larsen T, Volgman AS. Sex, rhythm & death: the effect of sexual activity on cardiac arrhythmias and sudden cardiac death. Front Cardiovasc Med. 2022;9:987247. https://doi.org/10.3389/fcvm.2022.987247.
Jaarsma T. Sexual function of patients with heart failure: facts and numbers. ESC Heart Fail. 2017;4:3–7. https://doi.org/10.1002/ehf2.12108.
MornarJelavić M, Krstačić G, Perenčević A, Pintarić H. Sexual activity in patients with cardiac diseases. Acta Clin Croat. 2018;57:141–8. https://doi.org/10.20471/acc.2018.57.01.18.
Funding
Open access funding provided by Università degli Studi di Bari Aldo Moro within the CRUI-CARE Agreement.
Author information
Authors and Affiliations
Contributions
Conceptualization [Maria Cristina Carella, Marco Matteo Ciccone, Andrea Igoren Guaricci]; methodology [Eugenio Carulli, Fabio Amati, Umberto Carbonara]; investigation [Alessandro Stanca, Andrea Baggiano, Saima Mushtaq, Gianluca Pontone]; writing—original draft preparation [Maria Cristina Carella, Cinzia Forleo, Alessandro Stanca, Paolo Basile]; writing—review and editing [Fabio Amati, Andrea Baggiano, Saima Mushtaq, Gianluca Pontone]; visualization [Eugenio Carulli, Paolo Basile, Umberto Carbonara]; supervision [Cinzia Forleo, Marco Matteo Ciccone, Andrea Igoren Guaricci]. All authors have read and agreed to the published version of the manuscript.
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Maria Cristina Carella and Cinzia Forleo contributed equally as first authors.
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
Carella, M.C., Forleo, C., Stanca, A. et al. Heart Failure and Erectile Dysfunction: a Review of the Current Evidence and Clinical Implications. Curr Heart Fail Rep 20, 530–541 (2023). https://doi.org/10.1007/s11897-023-00632-y
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11897-023-00632-y