To the Editor, In their commentary on our recently published paper ‘History of erectile dysfunction as a predictor of poor physical performance after an acute myocardial infarction’,Kalka and Gebala remind… Click to show full abstract
To the Editor, In their commentary on our recently published paper ‘History of erectile dysfunction as a predictor of poor physical performance after an acute myocardial infarction’,Kalka and Gebala remind us of the prognostic relevance of erectile dysfunction (ED) in patients with coronary artery disease (CAD) and outline how a common pathogenesis for ED and CAD may be found in a dysfunctional vascular endothelium. They also agree with our hypothesis that evaluation of the history of ED could provide a basis for identification of a subset of fragile patients, that would need more targeted cardiac rehabilitation activities after an acute myocardial infarction (AMI). Kalka and Gebala present their doubt about a possible bias that could have been introduced in our study by the inclusion of a small number of post-AMI patients with a history of ‘no sexual activity’ in the previous six months. Patients are usually classified as having ‘no sexual activity’ when their score is less than five on the International Index of Erectile Function Questionnaire (IIEF-5); such a low score could indeed be an expression both of true ED and absence of sexual activity due to reasons different from ED (a situation that is not identifiable with the IIEF-5 questionnaire). In order to clarify this doubt, we decided to review our original data and repeat a statistical analysis after exclusion of the 15 patients with IIEF-5<5. A significant correlation persisted between ED (ED degree, IIEF-5 score) and the objective measures of physical performance. Even after exclusion of patients with ‘no sexual activity’, the remaining patients with ED walked shorter distances at the final six-minute walk test (6MWT-out: 510 113m vs 564 94m; p1⁄4 0.006), sustained lower effort in the cardiopulmonary exercise test (W-max: 83.4 29.3 vs 108.9 34.4W; p< 0.001) and reached lower peak oxygen uptake (peak-VO2: 18.6 5.4 vs 20.9 5.3ml/Kg/min; p1⁄4 0.033) than post-AMI patients without history of ED. The negative linear correlations already described between 6MWTout, peak-VO2 and W-max with degree of ED, as well as their positive correlations with IIEF-5 scores persisted even after exclusion of the sub-group of patients with ‘no sexual activity’ (6MWT-out vs degree of ED: r1⁄4 0.328, p< 0.001; peak-VO2 vs degree of ED: r1⁄4 0.203, p1⁄4 0.039; W-max vs degree of ED: r1⁄4 0.386, p< 0.001; 6MWT-out vs IIEF-5 score: r1⁄4 0.365, p< 0.001; peak-VO2 vs IIEF-5 score: r1⁄4 0.238, p1⁄4 0.015; W-max vs IIEF-5 score: r1⁄4 0.396, p< 0.001). In conclusion, we can confirm that history of ED constitutes a prognostic indicator of poor physical performance in post-AMI patients. We agree with the suggestion by Kalka and Gebala that the introduction of the IIEF-5 questionnaire for the clinical assessment of complicated post-AMI patients referred for cardiac rehabilitation could provide an easy and valuable tool that could help in stratifying cases needing improved interventions.
               
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