Erectile dysfunction: the need to be evaluated, the right to be treated.

Erectile dysfunction (ED) is commonly associated with cardiovascular disease, which has potentially fatal consequences if not managed appropriately. Physicians and patients for a number of reasons commonly ignore ED. Increased awareness of the health consequences of ED would encourage men and health care professionals to address this condition more freely, permitting appropriate screening and treatment of cardiovascular disease. Concerns about the risks of treating ED in the cardiac patient should not prevent ED from being discussed and we suggest that early acknowledgment of ED might prevent cardiovascular morbidity and even mortality. Specific guidelines for the management of ED in cardiac patients, produced by 2 expert panels, can also be applied to men without known cardiovascular disease.

Report of the National Heart, Lung, and Blood Institute working group on outcomes research in cardiovascular disease.

The National Heart, Lung, and Blood Institute convened a working group on outcomes research in cardiovascular disease (CVD). The working group sought to provide guidance on research priorities in outcomes research related to CVD. For the purposes of this document, "outcomes research" is defined as investigative endeavors that generate knowledge to improve clinical decision making and healthcare delivery to optimize patient outcomes. The working group identified the following priority areas: (1) national surveillance projects for high-prevalence CV conditions; (2) patient-centered care; (3) translation of the best science into clinical practice; and (4) studies that place the cost of interventions in the context of their real-world effectiveness. Within each of these topics, the working group described examples of initiatives that could serve the Institute and the public. In addition, the group identified the following areas that are important to the field: (1) promotion of the use of existing data; (2) facilitation of collaborations with other federal agencies; (3) investigations into the basic science of outcomes research, with an emphasis on methodological advances; (4) strengthening of appropriate study sections with individuals who have expertise in outcomes research; and (5) expansion of opportunities to train new outcomes research investigators. The working group concluded that a dedicated investment in CV outcomes research could directly improve the care delivered in the United States.

Erectile dysfunction therapy in special populations and applications: coronary artery disease.

Erectile dysfunction (ED) and coronary artery disease (CAD) interact in complex ways: ED is increasingly recognized as a harbinger or risk factor for CAD; a small proportion of cases (about 1%) of acute coronary syndromes (ACS), including acute myocardial infarction and sudden cardiac death, occur during or after sexual activity; the absolute risk associated with coitus, including that associated with the use of phosphodiesterase 5 (PDE5) inhibitors to treat ED, is extremely low; virtually all patients experiencing ACS have previously existing (but usually undiagnosed) CAD; and patients often have ED after ACS as a result of psychological factors or drugs, such as beta-blockers, used to treat CAD. The Princeton Guidelines provide a pragmatic approach to stratifying the risk of ACS in patients with established CAD or at high risk for future ACS. Only a minority of patients destined to experience ACS, including those events related to coitus, have established CAD. Yet, most have > or =2 coronary risk factors. The most pragmatic approach to decreasing the risk of ACS in such individuals is to maximize risk factor control and institute combination pharmacotherapy, including statins. The PDE5 inhibitors ameliorate not only ED but also endothelial cell dysfunction. Research to establish the role for PDE5 inhibitors in the prevention and control of ACS is in its early stages. The recognition that ED is a potential harbinger of underlying CAD and future ACS is an important milestone in the management of ED. Progress in integrating PDE5 inhibitors into clinical practice will depend on the success with which patients with ED are evaluated and aggressively treated for endothelial cell dysfunction.

Nurse management for hypertension. A systems approach.

BACKGROUND: Standard office-based approaches to controlling hypertension show limited success. Such suboptimal hypertension control reflects in part the absence of both an infrastructure for patient education and frequent, regular blood pressure (BP) monitoring. We tested the efficacy of a physician-directed, nurse-managed, home-based system for hypertension management with standardized algorithms to modulate drug therapy, based on patients' reports of home BP. METHODS: We randomized outpatients requiring drug therapy for hypertension according to the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC VI) criteria to receive usual medical care only (UC, n = 76) or usual care plus nurse care management intervention (INT, n = 74) over a 6-month period. RESULTS: Patients receiving INT achieved greater reductions in office BP values at 6 months than those receiving UC: 14.2 +/- 18.1 versus 5.7 +/- 18.7 mm Hg systolic (P < .01) and 6.5 +/- 10.0 versus 3.4 +/- 7.9 mm Hg diastolic, respectively (P < .05). At 6 months, we observed one or more changes in drug therapy in 97% of INT patients versus 43% of UC patients, and 70% of INT patients received two or more drugs versus 46% of UC. Average daily adherence to medication, measured by electronic drug event monitors, was superior among INT subjects (mean +/- SD, 80.5% +/- 23.0%) than among UC subjects (69.2 +/- 31.1%; t(113) = 2.199, P = .03). There were no significant adverse drug reactions in either group. CONCLUSIONS: Telephone-mediated nurse management can successfully address many of the systems-related and patient-related issues that limit pharmacotherapeutic effectiveness for hypertension.

Contemporary management of silent ischemia: the role of ambulatory monitoring.

Silent ischemia is highly prevalent among patients with ischemic heart disease and is associated with a poor prognosis in moderate/high risk outpatients who either exhibit exercise- or pharmacological-induced myocardial ischemia, or in those patients who demonstrate silent ischemia following an acute coronary syndrome. Pharmacotherapy, including beta-blockers, angiotensin-converting enzyme inhibitors, statins, calcium channel antagonists and antiplatelet agents, have all demonstrated a reduction in silent ischemia and an improvement in cardiac prognosis. The management of patients with ischemic heart disease is currently based on patients' report of anginal symptoms: documentation of silent ischemia, usually using ambulatory electrocardiography, is not incorporated into the routine management of coronary artery disease. Yet studies comparing ambulatory electrocardiography with exercise testing have shown these tests to be complementary. We review the evidence concerning the prognostic value of ambulatory electrocardiography for monitoring silent ischemia and the prognostic value of attenuating silent ischemia. Mitigation of silent ischemia improves cardiac prognosis and ambulatory electrocardiographic monitoring before and after treatment of silent ischemia can play a valuable role in the management of coronary artery disease.

Psychosocial treatment within sex by ethnicity subgroups in the Enhancing Recovery in Coronary Heart Disease clinical trial.

OBJECTIVE: Intervening in depression and/or low perceived social support within 28 days after myocardial infarction (MI) in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial did not increase event-free survival. The purpose of the present investigation was to conduct post hoc analyses on sex and ethnic minority subgroups to assess whether any treatment subgroup is at reduced or increased risk of greater morbidity/mortality. METHODS: The 2481 patients with MI (973 white men, 424 minority men, 674 white women, 410 minority women) who had major or minor depression and/or low perceived social support were randomly allocated to usual medical care or cognitive behavior therapy. Total mortality or recurrent nonfatal MI (ENRICHD primary endpoint) and cardiac mortality or recurrent nonfatal MI (secondary endpoint) were analyzed as composite endpoints by group for time to first event using Cox proportional hazards regression. RESULTS: There was a trend in the direction of treatment efficacy for white men for the primary endpoint (hazard ratio [HR], 0.80; 95% confidence interval, 0.61-1.05; p =.10) and a significant (p <.006, Bonferroni corrected) effect for the secondary endpoint (HR, 0.63; 95% CI, 0.46-0.87; p =.004). In contrast, the HRs for each of the other three subgroups were nonsignificant. The magnitude of differences in treatment effects between white men and the other subgroups remained significant for the secondary endpoint (p =.04) after adjustment for age, education, living alone, antidepressant use, comorbidity score, cardiac catheterization, ejection fraction, history of hypertension, and major depression. CONCLUSIONS: White men, but not other subgroups, may have benefited from the ENRICHD intervention, suggesting that future studies need to attend to issues of treatment design and delivery that may have prevented benefit among sex and ethnic subgroups other than white men.

Efficacy and safety of sildenafil citrate in men with erectile dysfunction and stable coronary artery disease.

This was a double-blind, placebo-controlled, flexible-dose study of the efficacy and safety of sildenafil in men with erectile dysfunction (ED) and clinically stable coronary artery disease (CAD). Patients were randomized to receive sildenafil or placebo for 12 weeks. Primary outcomes were questions 3 and 4 of the International Index of Erectile Function (IIEF). Secondary outcomes included the other IIEF questions and functional domains, the Life Satisfaction Checklist, the Erectile Dysfunction Inventory of Treatment Satisfaction, 2 global efficacy assessment questions, and intercourse success rate. By week 12, sildenafil-treated patients (n = 70) showed significant improvements on questions 3 and 4 compared with placebo-treated patients (n = 72; p <0.01). Larger percentages of sildenafil-treated patients reported improved erections (64%) and improved intercourse (65%) compared with placebo-treated patients (21% and 19%, respectively). Sildenafil-treated patients were highly satisfied with treatment and their sexual life compared with placebo-treated patients. Forty-seven percent of sildenafil- and 32% of placebo-treated patients experienced adverse events, including transient headache, hypertension, flushing, and dyspepsia. There were no serious drug-related cardiovascular effects. Thus, sildenafil is an effective and well-tolerated treatment for ED in men with CAD. Sildenafil was not associated with additional safety risks in this patient population.

Usefulness of ambulatory electrocardiographic monitoring for myocardial ischemia after coronary bypass.

Cardiac patients with asymptomatic myocardial ischemia have a poor prognosis. Ambulatory electrocardiographic monitoring can help to ensure that these patients, who are unaware of their high-risk status, are relieved of residual myocardial ischemia in response to cardioprotective medication, and rendered as low cardiac risk.

Application of a nurse-managed inpatient smoking cessation program.

This study reports on the effectiveness of a nurse case-managed smoking cessation program for general hospitalized patients that was continued for 3 years after clinical trials were completed. Patients admitted to the hospital who smoked were offered a smoking cessation program during their hospitalization. The program included physician advice, bedside education and counseling with a nurse specially trained in smoking cessation techniques, take-home materials (videotape, workbook, and relaxation audiotape), nicotine replacement therapy if requested or indicated, and four nurse-initiated post-discharge telephone counseling calls. Of the 2091 patients identified as smokers, 52% enrolled in the program, 18% wanted to quit on their own, 20% did not want to quit, and 10% were ineligible. The 12-month self-reported cessation rate (7-day point prevalence) was 35% if patients lost to follow-up were considered smokers, 49% if not. Patients hospitalized for cancer, cardiovascular, or pulmonary reasons were most likely to participate and had the highest self-reported cessation rates (63%, 57%, and 46%, respectively). This nurse-managed smoking cessation intervention was effective when it was put into standard hospital practice outside of its originating randomized clinical trial structure. The program, relatively inexpensive to deliver, appears to be acceptable to the majority of smokers who are hospitalized, resulted in high 1-year cessation rates, and can be extended to hospital employees and their families, work-sites, and communities on a cost-recovery basis.