#AskDrKK:How to handle patients on nitrates who wants to take Viagra group of drugs?

#DrKKAnswers:
1. Men treated with PDE-5 inhibitors (Viagra group of drugs) and nitrates are at risk for severe hypotension and syncope (loss of consciousness).
2. Co-administration of Viagra group of drugs (sildenafil) with isosorbide mononitrate or sublingual nitroglycerin lowers blood pressure (52/29 mmHg with isosorbide mononitrate and 36/21 mmHg with sublingual nitroglycerin).
3. In men on Viagra group of drugs with chest pain nitrates should not be administered for 24 hours (or longer in patients with renal or hepatic dysfunction) of sildenafil, 24 hours of vardenafil, or up to 48 hours of tadalafil.

#AskDrKK:Can heart patients take Viagra group of drugs Vardenafil and tadalafil?

#DrKKAnswers:
Tadalafil has the advantage of a longer duration of action.
Both drugs and sildenafil potentiate the BP lowering response to nitrates. This interaction lasts 24 hours with vardenafil and up to 48 hours with tadalafil.
Tadalafil, vardenafil and sildenafil are contraindicated with concomitant nitrate use.

#AskDrKK:Can heart patients take Viagra or Sildenafil?

#DrKKAnswers:
Sildenafil improves erectile function in patients with stable heart blockages. It is also effective in patients with hypertension, diabetes, and nonvascular organic or psychogenic causes for erectile dysfunction.
However it can lower blood pressure and interact with nitrates.
It lowers the systolic upper blood pressure by about 8 mmHg.
The BP lowering is not more when given with amlodipine.
Sildenafil also improves endothelial dysfunction and inhibits platelet activation.

#AskDrKK:Can drugs lead to sexual dysfunction?

#DrKKAnswers:
Always look for a reversible causes including drugs (thiazide diuretics, beta blockers, and lipid-lowering drugs)

Emedinews : Insulin nasal spray may slow Alzheimer's disease

Intranasal insulin therapy may have beneficial effects on cognition and function among patients with Alzheimer's disease, a pilot study suggested. Patients who received 20 IU of intranasal insulin daily for four months had improvements on delayed story recall tests (P=0.02, Cohen f effect size=0.36), according to Suzanne Craft, PhD, of the Veterans Affairs Puget Sound Health Care System in Seattle, and colleagues.

Study suggests that intranasal administration of insulin over a four-month period to patients with amnestic mild cognitive impairment or mild-to-moderate Alzheimer's disease improved delayed memory and preserved general cognition compared with placebo.

Insulin is critical for normal brain function, and dysregulation of its metabolism has been shown to contribute to the development of Alzheimer's disease. Because patients with Alzheimer's disease also exhibit decreased levels of insulin in the central nervous system, it has been hypothesized that raising these levels to normal might help maintain cognitive ability. (MedPage)

#AskDrKK:Can heart patients have sex?

#DrKKAnswers:
1. Low risk patients can safely initiate or resume sexual activity and should receive treatment for sexual dysfunction.
2. Intermediate risk patients should receive further evaluation by stress testing.
3. High risk patients should be stabilized by appropriate therapy before resuming sexual activity or being treated for sexual dysfunction.

#AskDrKK:Can patient with hypertrophic cardiomyopathy be given Viagra or Sildenafil?

#DrKKAnswers:
The decrease in preload and after load by Viagra can increase the outflow obstruction in patients with hypertrophic cardiomyopathy culminating in an unstable hemodynamic state.

Source: N Engl J Med 1999; 341:700.

#AskDrKK:Is Viagra (sildenafil) in heart patients not on nitrates?

#DrKKAnswers:
1. Viagra is generally well tolerated in men with severe coronary disease not using nitrates. [1].
2. Sildenafil is also safe during exercise in patients with stable coronary disease. [2].

References
1. N Engl J Med 2000; 342:1622.
2. JAMA 2002; 287:719.

#AskDrKK: Can Sildenafil (Viagra) cause acute heart attack?

#DrKKAnswers:
1. Acute heart attack and sudden death have been described after sildenafil therapy [1, 2].
2. Seventy percent of the men who developed MI of SCD had known cardiovascular disease and several were using a nitrate concurrently with sildenafil [3].

References
1. Lancet 1998; 352:957.
2. N Engl J Med 1999; 341:700 .
3. Circulation 2000; 102:2516.

#AskDrKK: Can drugs lead to sexual dysfunction?

#DrKKAnswers:
Always look for a reversible causes including drugs (thiazide diuretics, beta blockers, and lipid-lowering drugs)

#AskDrKK:How common is sexual dysfunction after acute heart attack?

#DrKKAnswers
1. Sexual dysfunction is common due to concern about risk; side effects of drugs (diuretics, beta blockers, lipid-lowering drugs) and due to risk factors like high lipis, diabetes, smoking, hypertension and psychologic factors [1].
2. Erectile dysfunction after a heart attack occur in one-half to three-quarters of patients. [2,3].
3. ED is also seen after bypass surgery (though less common)
4. Both men and women have less sexual activity and less satisfaction with sexual act after a heart attack [1].
5. Psychologic causes for sexual dysfunction are due to perceptions of their illness [4].
6. Worries about triggering a heart attack or sudden death and depression and anxiety of the disease especially the occurrence of a heart attack contribute. [5,6].
7. The fear can be in the mind of the patient or the spouse.
8. Most doctors do not discuss this issue of sexual act with post-heart attack patients or their spouses [7,8].
9. Counseling may improve sexual function [9].
10. Exercise stress testing is used to measure exercise tolerance and tolerance for sex..

References
1. Am J Cardiol 2000; 85:1283.
2. Arch Sex Behav 1986; 15:499.
3. Chest 1986; 90:681.
4. BMJ 1996; 312:1191.
5. Am J Cardiol 2000; 86:41F.
6. Am J Cardiol 2000; 86:46F.
7. Am J Cardiol 2000; 86:38F.
8. Arch Intern Med 1980; 140:38.
9. J Behav Med 1984; 7:61.

#AskDrKK:Can heart patients have sex?

#DrKKAnswers:
1. Low risk patients can safely initiate or resume sexual activity and should receive treatment for sexual dysfunction.
2. Intermediate risk patients should receive further evaluation by stress testing.
3. High risk patients should be stabilized by appropriate therapy before resuming sexual activity or being treated for sexual dysfunction.

#AskDrKK:Which patients are at intermediate risk for getting heart attack after sex?

#DrKKAnswers:
1. No symptoms and three or more cardiovascular risk factors (excluding gender); a sedentary lifestyle is considered a risk factor
2. Moderate, stable angina
3. A recent heart attack (> 2 weeks but less than 6 weeks); in patients who have not undergone revascularization. The risk can be assessed with stress testing.
4. Asymptomatic left ventricular dysfunction with left ventricular pumping ejection fraction <40 percent or New York Heart Association class II heart failure. 5. Non cardiac manifestations of atherosclerotic disease, such as peripheral vascular disease or prior stroke or transient ischemic attack.


Source: Am J Cardiol 2005; 96:313.

#AskDrKK:Which patients are at high risk for getting heart attack after sex?

#DrKKAnswers:
1. Patients with unstable or refractory angina
2. Uncontrolled hypertension
3. New York Heart Association class III or IV heart failure
4. A heart attack within the past two weeks
5. High-risk irregular heart rhythms
6. Patients with obstructive hypertrophic cardiomyopathy
7. Patients with moderate-to-severe valvular disease, particularly aortic stenosis

Source: Am J Cardiol 2005; 96:313

#AskDrKK: Can the risk of heart attack after sexual act be minimized?

#DrKKAnswers:
a. The triggers to acute heart attack are increase in heart rate, blood pressure, and myocardial oxygen demand, as well as increased platelet agreeability and coagulation in combination with a vulnerable coronary plaque [1].
b. Drugs that reduce heart rate or blood pressure or inhibit platelet aggregation reduces the risk of triggers of heart attack.
c. Beta blockers minimize or eliminate angina heart pain during sexual act.
d. The Determinants of Myocardial Infarction Onset Study showed that beta blockers reduced the risk of MI following anger [2] but not sexual act [3].
e. Aspirin lowers the risk of heart attack following anger [3] and the morning waking hours [4].

References
1. J Am Coll Cardiol 1994; 23:809.
2. Circulation 1995; 92:1720.
3. JAMA 1996; 275:1405.
4. Circulation 1990; 82:897.

#AskDrKK:What is the absolute risk of acute heart attack after sex?

DrKKAnswers:


Sexual act is a transient trigger that increases risk of heart attack for only a two hour period. The absolute increase in risk is very small.

A 50 year-old man with no cardiac disease with an annual baseline risk of heart attack of 1 percent would increase his annual risk of heart attack to only 1.01 percent from weekly sexual activity.

A person with a high annual risk for a heart attack of 10 percent would increase the annual risk to only 10.1 percent from weekly sexual activity.

Source: Am J Cardiol 2000; 86:10F.

#AskDrKK:What is the risk of acute heart attack after a sexual act?

#DrKKAnswers:
Sexual act contributes to the onset of acute heart attack in only 0.9 percent of patients.

The relative risk of acute heart attack within two hours after sexual activity is 2.5. There is no increased risk of heart attack beyond this time period.

This risk is reduced in patients who undergo regular exercise. The risk is same irrespective of past history of heart disease.

Source:JAMA 1996; 275:1405.

Emedinews:Intensive medical treatment prevents second stroke not intra cranial stenting

Patients at a high risk for a second stroke who received intensive medical treatment had fewer strokes and deaths than patients who received a brain stent in addition to the medical treatment. The investigators published the results in the online first edition of the New England Journal of Medicine.

The National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health, funded the trial. The medical regimen included daily blood-thinning medications and aggressive control of blood pressure and cholesterol.

New enrolment in the study was stopped in April because early data showed significantly more strokes and deaths occurred among the stented patients at the 30-day mark compared to the group who received the medical management alone.

In addition to the intensive medical program, half of the patients in the study received an intervention of a self-expanding stent that widens a major artery in the brain and facilitates blood flow. One possible explanation for the higher stroke rate in the stented group is that patients who have had recent stroke symptoms sometimes have unstable plaque in their arteries which the stent could have dislodged, the study authors suggest. The study device, the Gateway-Wingspan intracranial angioplasty and stenting system, is the only system currently approved by the U.S. Food and Drug Administration (FDA) for certain high-risk stroke patients. The study participants were in the highest risk category, with blockage or narrowing of arteries of 70 to 99 percent.

Intensive medical management included a daily dosage of 325 milligrams of aspirin; 75 milligrams a day of Clopidogrel, for 90 days after enrollment; and aggressive management of key stroke risk factors—high blood pressure and high levels of low density lipoprotein (LDL), the unhealthy form of cholesterol. All patients also participated in a lifestyle modification program which focused on quitting smoking, increasing exercise, and controlling diabetes and cholesterol.

"The SAMMPRIS study results have immediate implications for clinical practice. Stroke patients with recent symptoms and intracranial arterial blockage of 70 percent or greater should be treated with aggressive medical therapy alone.

(New England Journal of Medicine, published online September 7, 2011).

#AskDrKK:What sexual advice to give to a patient with stable angina?

#DrKKAnswers:
1. Patients with angina often become symptomatic during sexual act (1,2).
2. 65 percent ends up with heart chest pain enough to stop activity (2).
3. Beta blockers and/or prophylactic sublingual nitrates, can prevent heart pain in these patients and permit a normal sex life (2).
4. Post angioplasty and bypass surgery patient do not carry excess risk
5. Asymptomatic chronic heart blockage patients also do not have an increased risk of symptoms during sexual act.

References
1. Arch Intern Med 1970; 125:987.
2. Int Rehabil Med 1981; 3:35.

#AskDrKK: Which position is better for sex in heart patients?

#DrKKAnswers:
There is no difference in heart rate (114 vs 117) or blood pressure (163/81 vs 161/77 mmHg) between man on top or man on bottom [1]. However there is slightly lower minute oxygen consumption for men in the supine position, but this lasts only for a brief period during orgasm [2].

References
1. Am Heart J 1976; 92:274.
2. Arch Intern Med 1984; 144:1745.