Patients who invite conversations on decreasing sexual performance are always welcome. This one like most enjoys a good relationship with his partner and would like to maintain their strong interest in having sexual intercourse. He is happily married and in a stable relationship, has never suffered from depression. He has however noticed increasing difficulty initiating and maintaining erection and he no longer experiences the usual nighttime and early morning kick and spontaneous erection. The loss of the usual morning erection did not go unnoticed by his very attentive partner of 34 years. All these experiences and symptoms are consistent with Erectile Dysfucntion (ED). He nevertheless has always been in good health, except for the usual mild hypertension and borderline cholesterol. With this current erectile difficulty, we are both eager to try some viagra. Well not so fast I would like to caution.

Erectile dysfunction (ED) itself happens to be an independent risk factor for heart disease, cardiovascular event and heart attacks. Hence clinical assessment for co-occurring heart problem is warranted before handing over a prescription of viagra or other similar medicines for the treatment of Erectile Dysfunction. Sexual activity can be unsafe in the face of underlying cardiovascular disease. Even worse, jumping into treating ED when there is a likelyhood of an unattended underlying cardiovascular disease is an invitation for serious problems such as a heart attack and sudden death. Deaths have been known to occur right in the middle of sexual activity. ED is a risk that equals moderate tobacco use, for cardiovascular disease. Performance enhancement may well precipitate a cardiac event in a high risk individual. It is prudent to rule out and manage co-occurring heart disease in select individuals before prescribing and or encouraging continued sexual activity.

In primary care it is good practice to have a high index of suspicion, in select individuals when appropriate, to search, uncover and treat co-occurring coronary heart disease before giving out viagra, cialis or their like prescriptions, the so called phosphodiesterase type 5 (PDE-5) inhibitor therapy. Fortunately, first-line treatment for ED includes lifestyle modification (smoking cessation, exercise, and weight loss). 

For example, nearly 30% of obese men will have improvement in ED symptoms by just exercising regularly and losing weight in efforts to bring the BMI below 30.