Undoubtedly, heart disease is and will continue to be one of the major health problems of modern society. Approximately one death every forty seconds occurs due to cardiovascular (CV) disease in the United States alone and arterial hypertension is one of the greatest culprits for it[1]. Considering the fact that around 25% of the global population suffer from arterial hypertension, predicted to reach 1.5 billion people in the foreseeable future, it is easily deducted that a respectful part of the general population is under major and constant CV risk[2,3].

Abstract | Full Text | Full Text PDF | PubMed | Scopus (95) | Google ScholarSee all References During this period, 130 deaths were reported to the US FDA; 41 of these men died or had cardiac arrest within 4 to 5 hours after taking sildenafil, and 27 died or had cardiac arrest either during or immediately after sexual activity. The average age of these men was 64 years. Of the 77 men in this group who died of documented cardiovascular-related events, 41 died of definite or suspected myocardial infarction, 27 died after cardiac arrest, and 6 had symptoms of cardiac disease at the time of death. Sixteen of the men had taken nitroglycerin or organic nitrates in association with sildenafil; another 3 had nitroglycerin in their possession at the time of death. In 48 men, the cause of death was unknown, and another 3 died of cerebrovascular accidents. Overall, it was concluded that sildenafil was not associated with an excess of cardiovascular death.


The American College of Cardiology is a 52,000-member medical society that is the professional home for the entire cardiovascular care team. The mission of the College is to transform cardiovascular care and to improve heart health. The ACC leads in the formation of health policy, standards and guidelines. The College operates national registries to measure and improve care, offers cardiovascular accreditation to hospitals and institutions, provides professional medical education, disseminates cardiovascular research and bestows credentials upon cardiovascular specialists who meet stringent qualifications.

** Indeterminate risk patients include diabetics, those with mild or moderate stable angina pectoris, past myocardial infarction (2-8 wks) without intervention awaiting exercise electrocardiography, congestive heart failure (NYHA class III), and noncardiac sequelae of atherosclerotic disease (eg, peripheral artery disease and a history of stroke or transient ischemic attack); this patient with ED may require assessment for additional vascular disease using carotid intima-media thickness or ankle-brachial index and subsequent reclassification to low or high risk.
Since their introduction in the therapeutic field, more than a decade ago, PDE-5 inhibitors have revolutionized the treatment of sexual dysfunction. By blocking the activity of PDE-5 isoenzyme, localized throughout the smooth muscle cells of the vasculature (genital vessels included), PDE-5 inhibitors increase the levels of cyclic guanosine monophosphate thus exerting vasodilating properties and facilitating penile erection[40-42]. Due to these properties, sildenafil was the first drug of its class to receive wide acceptance. Its short half-life, food interactions and the associated visual disturbances however, paved the way for the development of newer PDE-5 inhibitors. As such vardenafil with its more rapid onset of action, and tadalafil with its longer half-life and the lack of food interactions or side effects, have offered significant alternatives to sildenafil[43-50].

Abstract | Full Text | Full Text PDF | PubMed | Scopus (95) | Google ScholarSee all References In conclusion, sildenafil, when used alone, seems to produce minimal decreases in blood pressure level, which are well tolerated in healthy patients and in those with stable ischemic coronary disease.3x3Zusman, RM, Morales, A, Glasser, DB, and Osterloh, IH. Overall cardiovascular profile of sildenafil citrate. Am J Cardiol. 1999; 83: 35C–44C
A number of over-the-counter herbal supplements claim to treat ED. However, according to the Mayo Clinic, you should avoid products labeled as “herbal Viagra.” These supplements can increase blood flow and cause dangerous drops in blood pressure. Risk may be particularly high for men who are using nitrates. Herbal Viagra can also interact with other prescription drugs. Herbal Viagra products may contain potentially toxic compounds that aren’t listed on the label.
Despite physician’s inexperience and patient’s reluctance to disclose sexual dysfunction problems, attempts to estimate the magnitude of this clinical condition have predicted that over 150 million men worldwide experience some degree of erectile dysfunction. Several studies have demonstrated a wide range regarding the prevalence of erectile dysfunction, which is even higher in patients with essential hypertension where the relative risk is approximately two times higher than in normotensive individuals[6-11]. The etiology can be found in the structural and functional abnormalities of the penile arteries induced by high blood pressure. Smooth muscle hypertrophy, stenotic lesions due to atherosclerosis and impaired blood flow are among the prominent structural alterations whereas endothelial dysfunction and the defective nitric oxide-induced vasodilatory mechanism belong to the main functional abnormalities induced by increased blood pressure[12,13]. As a matter of fact, sexual dysfunction is encountered more frequently that it is indeed believed underlining the need for a more proper and concrete assessment.
The first step in the process is always to reevaluate if the medication that’s causing the problem is even necessary in the first place. Do you still need the medication(s) that you’re taking? When you’re experiencing medically induced ED, this has to be your starting point. Obviously you shouldn’t make this decision on your own. However, reevaluating your need for medication can be a simple conversation with your doctor. Remind your healthcare provider of the medications you’re taking, and explain any symptoms or side effects—like ED. Going off of medication might sound like an extreme step, but I’ve seen many examples of this in practice.
Since time immemorial, TCM has been adopted by many cultures and is widely practiced in Asian countries despite paucity of level 1 clinical evidence and limited published safety records. TCM is more congruent with Asian values, beliefs and philosophical orientation to health, simple administration, readily available and ease of access or procurement, and general belief that TCM is safer. While Asian males are clearly different from their Western counterparts with respect to biology, culture and beliefs, the practice of TCM appears to be adopted by many Western nations lately. Many men seek TCM to avoid embarrassing visits to physicians and potential side effects of pharmaceutical drugs, or after becoming frustrated with the outcome of modern medicine. Patients are choosing to take more responsibility for their health by exploring a variety of non-pharmaceutical drugs and wellness practices. Furthermore, TCM such as herbal medicine does not address a specific organ system only and is meant to restore and realign the vital energy within the body, which is responsible for ageing, clinical diseases and the deterioration of bodily function; while in Western medicine, each pill is intended for a specific organ/system and that a patient may need a collection of pills to treat multiple comorbidities, rendering modern medicine less attractive to TCM.
Relation between erectile dysfunction prevalence and type of coronary syndrome (A). Time interval (months) between erectile dysfunction and coronary artery disease symptom onset in chronic coronary syndrome according to the number of vessels involved (B). ACS, acute coronary syndrome; CCS, chronic coronary syndrome, G1: ACS and 1-VD; G2: ACS and 2-,3-VD; G3: CCS. VD, vessel disease; C: the control group with normal coronary angiography. With permission from Montorsi et al.15
Qigong is a form of breathing exercises commonly practised in Asia to maintain health (53). In a cross-sectional population-based comparison study in Taiwan, individuals practising Qigong demonstrate higher SF-36 scores in the domains of physical functioning, role limitations due to physical problems, bodily pain, general health and vitality (54). Techniques to concentrate the energy or qi in the pelvis or genitals are regularly practised, but the effects of Qigong on ED have not been studied.
Abstract | Full Text | Full Text PDF | PubMed | Scopus (24) | Google ScholarSee all References Erectile function relies on the arterial blood supply from the internal pudendal arteries, which are branches of the hypogastric arterial system (Figure 1). Substantial increases in internal pudendal arterial flow result in pressures within the penis that are comparable to systemic arterial levels.12x12Rampin, O and Giuliano, F. Central control of the cardiovascular and erection systems: possible mechanisms and interactions. Am J Cardiol. 2000; 86: 19F–22F

Normal male sexual function requires a complex interaction of vascular, neurological, hormonal, and psychological systems. The initial obligatory event is acquisition and maintenance of an erect penis, which is a vascular phenomenon. Normal erections require blood flow into the corpora cavernosae and corpus spongiosum. As the blood accelerates, the pressure within the intracavernosal space increases dramatically to choke off penile venous outflow. This combination of increased intracavernosal blood flow and reduced venous outflow allows a man to acquire and maintain a firm erection.

In TCM, the meridian system is thought to represent a path through which the life energy qi flows and as discussed in earlier section, the “Jing” (kidney) qi plays an important role in penile erection. Acupuncture helps to correct the imbalances to relieve physical symptoms by stimulating various meridian points. The Shensu (BL23), Zusanli (ST36) and Neiguan (PC6) points represents important acupoints for penis stimulation and thus has a positive homeostatic effect on the autonomic nervous system, and potentially modulate NO release (55,56). While some studies have showed up to a third of patients reported improvement in penile erection and sexual activity, systematic review showed insufficient data to conclude that acupuncture is an effective intervention for treating ED (56,57). Therefore, further scientific research is required to investigate whether there are specific benefits of acupuncture for men with ED before acupuncture can be accepted as evidence-based practice.
In another study, 60 patients underwent stress exercise cardiovascular testing and Doppler ultrasonography for measurement of their cavernosal artery peak systolic velocity (PSV).17x17Kawanishi, Y, Lee, KS, Kimura, K et al. Screening of ischemic heart disease with cavernous artery blood flow in erectile dysfunctional patients. Int J Impot Res. 2001; 13: 100–103

For oral erectile dysfunction medicines to work as desired, they must be used properly in the first place. This means taking the medicine 30–45 minutes before engaging in sexual intimacy; taking the drug on an empty stomach or at least avoiding a heavy or high-fat meal before taking the drug (this is especially important when using sildenafil); and engaging in adequate genital stimulation before attempting intercourse. Drinking small amounts of alcohol (one to two drinks) should not compromise the effectiveness of erectile dysfunction medicines, but larger amounts of alcohol can diminish a man’s ability to have an erection.
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