American Journal of Men's Health http://jmh.sagepub.com/
Effect of Endurance Cardiovascular Training Intensity on Erectile Dysfunction Severity in Men With Ischemic Heart Disease Dariusz Kalka, Zygmunt A. Domagala, Piotr Kowalewski, Leslaw Rusiecki, Piotr Koleda, Wojciech Marciniak, Jacek Dworak, Jerzy Adamus, Joanna Wojcieszczyk, Edel Pyke and Witold Pilecki Am J Mens Health published online 30 July 2014 DOI: 10.1177/1557988314544156 The online version of this article can be found at: http://jmh.sagepub.com/content/early/2014/07/28/1557988314544156
Published by: http://www.sagepublications.com
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544156 research-article2014
JMHXXX10.1177/1557988314544156American Journal of Men’s HealthDariusz et al.
Article
Effect of Endurance Cardiovascular Training Intensity on Erectile Dysfunction Severity in Men With Ischemic Heart Disease
American Journal of Men’s Health 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988314544156 ajmh.sagepub.com
Dariusz Kalka, MD, PhD1,2, Zygmunt A. Domagala, MD, PhD1, Piotr Kowalewski, MD, PhD3, Leslaw Rusiecki, MD, PhD1, Piotr Koleda, MD, PhD1, Wojciech Marciniak, MD4, Jacek Dworak, MD5, Jerzy Adamus, MD, PhD, Joanna Wojcieszczyk, MSci, PhD6, Edel Pyke1, and Witold Pilecki, MD, PhD1
Abstract The protective effect of physical activity on arteries is not limited to coronary vessels, but extends to the whole arterial system, including arteries, in which endothelial dysfunction and atherosclerotic changes are one of the key factors affecting erectile dysfunction development. The objective of this study was to report whether the endurance training intensity and training-induced chronotropic response are linked with a change in erectile dysfunction intensity in men with ischemic heart disease. A total of 150 men treated for ischemic heart disease, who suffered from erectile dysfunction, were analyzed. The study group consisted of 115 patients who were subjected to a cardiac rehabilitation program. The control group consisted of 35 patients who were not subjected to any cardiac rehabilitation. An IIEF-5 (International Index of Erectile Function) questionnaire was used for determining erectile dysfunction before and after cardiac rehabilitation. Cardiac training intensity was objectified by parameters describing work of endurance training. The mean initial intensity of erectile dysfunction in the study group was 12.46 ± 6.01 (95% confidence interval [CI] = 11.35-13.57). Final erectile dysfunction intensity (EDI) assessed after the cardiac rehabilitation program in the study group was 14.35 ± 6.88 (95% CI = 13.08-15.62), and it was statistically significantly greater from initial EDI. Mean final training work was statistically significantly greater than mean initial training work. From among the parameters describing training work, none were related significantly to reduction of EDI. In conclusion, cardiac rehabilitation program–induced improvement in erection severity is not correlated with endurance training intensity. Chronotropic response during exercise may be used for initial assessment of change in cardiac rehabilitation program–induced erection severity. Keywords cardiac rehabilitation, training intensity, chronotropic response, erectile dysfunction, ischaemic heart disease
Introduction Numerous studies have confirmed a correlation between erectile dysfunction (ED) and risk factors for atherosclerosis. Glucose and lipid metabolism disorders, obesity, smoking, and low level of leisure time physical activity have a substantial and proven impact on the development of ED (Bacon et al., 2006; Chao et al., 2012; Derby et al., 2000; Gandaglia et al., 2013). Therefore, a concentration of these factors observed in the population of patients with cardiovascular disease (CVD) makes this group especially exposed to ED (Guo et al., 2010). Actions undertaken as part of secondary prevention should lead to a limitation of the impact of risk
factors and thereby have a positive effect on erection quality in patients with CVD. One of the elements of 1
Wroclaw Medical University, Wroclaw, Poland Centre of Men’s Health, Wroclaw, Poland 3 Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany 4 Magodent Medical Centre, Warsaw, Poland 5 105th Military Hospital, General Surgery and Urology Unit, Zagan, Poland 6 University School of Physical Education, Wroclaw, Poland 2
Corresponding Author: Zygmunt Domagala, Department of Anatomy, Wroclaw Medical University, 50-367 Wroclaw/Breslau Chalubinskiego 6a, Poland. Email: [email protected]
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2
American Journal of Men’s Health
prevention programmes for cardiovascular patients is kinesiotherapy, which is a crucial element of cardiac rehabilitation (CR) and—as confirmed by various studies—has a beneficial effect on modifiable risk factors (Achatziefstratiou, Giakoumidakis, & Brokalaki, 2013). For patients with coronary artery disease, kinesiotherapy is a form of general exercise regimen overseen by a specialist. The protective effect of physical activity on arteries is not limited to coronary vessels, but extends to the whole arterial system, including arteries, in which endothelial dysfunction and atherosclerotic changes are one of the key factors affecting ED development (Haskell et al., 1994; Niebauer et al., 1997). Risk of complications from the cardiovascular system and individual exercise capacity determines individual exercise training intensity safe for each patient. Exercise training causes various intensity effects, which include a positive effect on erection quality in men with ischemic heart disease (IHD; Belardinelli, Lacalaprice, Faccenda, Purcaro, & Perna, 2005; Kalka et al., 2013). Considering the above, the authors attempted to answer the question whether endurance training intensity and training-induced chronotropic response are linked with a change in erection severity in men with IHD and ED.
Material and Method A total of 150 men treated for IHD (107 percutaneous coronary intervention, 43 coronary artery bypass graft), who scored ≤21 points in the initial IIEF-5 (International Index of Erectile Function) test were analyzed. The study group consisted of 115 patients (mean age 62.12 ± 8.71 years) who were subjected to a CR Phase 3 program. The control group consisted of 35 patients (mean age 61.43 ± 8.68 years) who were not subjected to CR Phase 3 program. Because of the documented beneficial influence of CR, no typical randomization was performed (Piepoli et al., 2014). To intentionally prevent the subjects from participating in CR would have been unethical. The authors tried to enroll as many participants as possible. However, some of the approached patients were reluctant and did not agree to participate. The patients who were reluctant to participate gave distance from the facility and the bother of having to attend exercises daily as reasons of their refusal. Thus, the great disproportions in the volume of the study groups. The two groups were statistically equivalent on all outcomes and potential covariates with the exception of Left ventricular end-diastolic dimension (LVEDD; Table 1). All patients gave their informed content to the study and completed the initial and final IIEF-5 tests fully (all categories). For patients from the study group, an inclusion criterion for the study was participation in at least 90% of exercises during the CR program.
Table 1. Inclusion Criteria. Basic inclusion criteria 1. No previous history of clinically significant pulmonary disease 2. Absence of any severe pelvis and vertebral column injury 3. No significant deviations in the initially performed resting spirometry test 4. Absence of any neurological and orthopedic disorders 5. No clinical symptoms of thyroid gland disorders 6. Absence of any stenocardial symptoms provoked by the cardiac training. 7. No hormonal treatment 8. Absence of any anatomical changes in penis; no benign prostatic hyperplasia; no prostate cancer 9. No repair surgery on abdominal aorta and/or iliac arteries 10. No psychiatric treatment and no antidepressant usage 11. Laboratory tests: (a) no anemia; (b) no deviations from the norm in thyrotropic hormone plasma levels
All patients were married and had the same sex partner for a long time. The inclusion criteria are given in Table 1. In all patients from the study group and the control group, a pharmacological treatment as per IHD treatment standards was applied. The treatment for IHD also included nonpharmacological protocols aimed at eliminating IHD risk factors, in particular at introducing prohealth physical activity and pharmacological treatment employing the use of acetylsalicylic acid and/or other antiplatelet drugs, IHD medication (short-acting nitrates, beta-adrenergic blocking agents, calcium antagonists), and hypolipidemic agents (statins, fibrates). As a result of concurrence of arterial hypertension, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARBs), and diuretics were administered (Jankowski et al., 2013). The criterion for exclusion of a patient from the study was a necessary dosage adjustment of drugs with a proven negative effect on erection and of drugs affecting the chronotropic reaction, carried out during the 6-month study. The inclusion and exclusion criteria were assessed by a therapeutic team in charge of CR (one internal diseases specialist, one cardiologist, and two physiotherapists). The participants’ case histories and results of additional tests were analyzed. If case of doubt, additional specialists were invited to consult. All respondents were informed of the study procedure and the key aspects of the studied issue and have given their written informed consent. There were no severe ventricular arrhythmias or conduction disturbances found in any of the patients in a 24-hour electrocardiograpic monitoring (Holter monitor).
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3
Dariusz et al. Table 2. Clinical Characteristics of the Study Groups (Patients With IHD and ED). Specification Numerical amount Age in years, mean ± SD BMI in kg/m2, mean ± SD Myocardial infarction, n (%) Hb concentration in g%, mean ± SD eGFR (MDRD), mean ± SD TC in mg%, mean ± SD TG in mg%, mean ± SD LDL-C in mg%, mean ± SD HDL-C in mg%, mean ± SD Echocardiography parameters, mean ± SD LVEDD in mm EF in % LA in mm RVEDD in mm IHD treatment, n (%) PTCA CABG Drugs, n (%) Beta-blockers ACEI/ARBs Statins/fibrats Diuretics Cardiovascular risk factors, n (%) Hypertension Diabetes type 2 Lipid disorders Smoking habits BMI ≥25 kg/m2 Inadequate leisure time physical activitya
Study group
Control group
p value
115 62.12 ± 8.75 28.67 ± 4.67 78 (67.83) 14.43 ± 0.91 77.23 ± 10.79 212.79 ± 46.03 173.89 ± 104.57 123.66 ± 39.20 48.48 ± 14.52
35 61.43 ± 8.81 27.08 ± 2.43 19 (54.29) 14.60 ± 0.79 81.03 ± 11.90 214.60 ± 41.10 169.07 ± 77.42 136.32 ± 39.03 46.73 ± 11.56
.6827 .0557 .2057 .3137 .0766 .8344 .8014 .1227 .5403
52.51 ± 5.72 56.75 ± 7.47 37.88 ± 3.97 23.00 ± 4.14
55.49 ± 3.72 54.97 ± 7.18 38.66 ± 3.49 24.31 ± 1.95
.0044* .2161 .2977 .0719
80 (69.57) 35 (30.43)
27 (77.14) 8 (22.86)
110 (95.65) 81 (70.43) 105 (91.30) 27 (23.47)
33 (94.29) 28 (80.00) 28 (80.00) 6 (17.14)
.5127 .5127 .6652 .3707 .1229 .5760
72 (62.61) 24 (20.86) 75 (65.22) 66 (57.39) 85 (73.91) 113 (98.26)
26 (74.29) 9 (25.71) 22 (62.86) 20 (57.14) 22 (62.86) 35 (100.00)
.2854 .7093 .9571 .8657 .2923 .9999
Note. IHD = ischemic heart disease; BMI = body mass index; Hb = hemoglobin; TC = total cholesterol; eGFR = estimated glomerular filtration rate; MDRD = modification of diet in renal diseases; TG = triglyceride; LDL-C = low-density lipoprotein; HDL-C = high-density lipoprotein; LVEDD = left ventricular end-diastolic dimension; EF = ejection fraction; LA = left atrial dimension; RVEDD = right ventricular end-diastolic dimension; PTCA = percutaneous transluminal coronary angioplasty; CABG = coronary artery bypass graft; ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blockers; CVD = cardiovascular disease. a. Inadequate physical activity means
Effect of Endurance Cardiovascular Training Intensity on Erectile Dysfunction Severity in Men With Ischemic Heart Disease Dariusz Kalka, Zygmunt A. Domagala, Piotr Kowalewski, Leslaw Rusiecki, Piotr Koleda, Wojciech Marciniak, Jacek Dworak, Jerzy Adamus, Joanna Wojcieszczyk, Edel Pyke and Witold Pilecki Am J Mens Health published online 30 July 2014 DOI: 10.1177/1557988314544156 The online version of this article can be found at: http://jmh.sagepub.com/content/early/2014/07/28/1557988314544156
Published by: http://www.sagepublications.com
Additional services and information for American Journal of Men's Health can be found at: Email Alerts: http://jmh.sagepub.com/cgi/alerts Subscriptions: http://jmh.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Jul 30, 2014 What is This?
Downloaded from jmh.sagepub.com at FLORIDA STATE UNIV LIBRARY on September 29, 2014
544156 research-article2014
JMHXXX10.1177/1557988314544156American Journal of Men’s HealthDariusz et al.
Article
Effect of Endurance Cardiovascular Training Intensity on Erectile Dysfunction Severity in Men With Ischemic Heart Disease
American Journal of Men’s Health 1–10 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1557988314544156 ajmh.sagepub.com
Dariusz Kalka, MD, PhD1,2, Zygmunt A. Domagala, MD, PhD1, Piotr Kowalewski, MD, PhD3, Leslaw Rusiecki, MD, PhD1, Piotr Koleda, MD, PhD1, Wojciech Marciniak, MD4, Jacek Dworak, MD5, Jerzy Adamus, MD, PhD, Joanna Wojcieszczyk, MSci, PhD6, Edel Pyke1, and Witold Pilecki, MD, PhD1
Abstract The protective effect of physical activity on arteries is not limited to coronary vessels, but extends to the whole arterial system, including arteries, in which endothelial dysfunction and atherosclerotic changes are one of the key factors affecting erectile dysfunction development. The objective of this study was to report whether the endurance training intensity and training-induced chronotropic response are linked with a change in erectile dysfunction intensity in men with ischemic heart disease. A total of 150 men treated for ischemic heart disease, who suffered from erectile dysfunction, were analyzed. The study group consisted of 115 patients who were subjected to a cardiac rehabilitation program. The control group consisted of 35 patients who were not subjected to any cardiac rehabilitation. An IIEF-5 (International Index of Erectile Function) questionnaire was used for determining erectile dysfunction before and after cardiac rehabilitation. Cardiac training intensity was objectified by parameters describing work of endurance training. The mean initial intensity of erectile dysfunction in the study group was 12.46 ± 6.01 (95% confidence interval [CI] = 11.35-13.57). Final erectile dysfunction intensity (EDI) assessed after the cardiac rehabilitation program in the study group was 14.35 ± 6.88 (95% CI = 13.08-15.62), and it was statistically significantly greater from initial EDI. Mean final training work was statistically significantly greater than mean initial training work. From among the parameters describing training work, none were related significantly to reduction of EDI. In conclusion, cardiac rehabilitation program–induced improvement in erection severity is not correlated with endurance training intensity. Chronotropic response during exercise may be used for initial assessment of change in cardiac rehabilitation program–induced erection severity. Keywords cardiac rehabilitation, training intensity, chronotropic response, erectile dysfunction, ischaemic heart disease
Introduction Numerous studies have confirmed a correlation between erectile dysfunction (ED) and risk factors for atherosclerosis. Glucose and lipid metabolism disorders, obesity, smoking, and low level of leisure time physical activity have a substantial and proven impact on the development of ED (Bacon et al., 2006; Chao et al., 2012; Derby et al., 2000; Gandaglia et al., 2013). Therefore, a concentration of these factors observed in the population of patients with cardiovascular disease (CVD) makes this group especially exposed to ED (Guo et al., 2010). Actions undertaken as part of secondary prevention should lead to a limitation of the impact of risk
factors and thereby have a positive effect on erection quality in patients with CVD. One of the elements of 1
Wroclaw Medical University, Wroclaw, Poland Centre of Men’s Health, Wroclaw, Poland 3 Dietrich Bonhoeffer Klinikum, Neubrandenburg, Germany 4 Magodent Medical Centre, Warsaw, Poland 5 105th Military Hospital, General Surgery and Urology Unit, Zagan, Poland 6 University School of Physical Education, Wroclaw, Poland 2
Corresponding Author: Zygmunt Domagala, Department of Anatomy, Wroclaw Medical University, 50-367 Wroclaw/Breslau Chalubinskiego 6a, Poland. Email: [email protected]
Downloaded from jmh.sagepub.com at FLORIDA STATE UNIV LIBRARY on September 29, 2014
2
American Journal of Men’s Health
prevention programmes for cardiovascular patients is kinesiotherapy, which is a crucial element of cardiac rehabilitation (CR) and—as confirmed by various studies—has a beneficial effect on modifiable risk factors (Achatziefstratiou, Giakoumidakis, & Brokalaki, 2013). For patients with coronary artery disease, kinesiotherapy is a form of general exercise regimen overseen by a specialist. The protective effect of physical activity on arteries is not limited to coronary vessels, but extends to the whole arterial system, including arteries, in which endothelial dysfunction and atherosclerotic changes are one of the key factors affecting ED development (Haskell et al., 1994; Niebauer et al., 1997). Risk of complications from the cardiovascular system and individual exercise capacity determines individual exercise training intensity safe for each patient. Exercise training causes various intensity effects, which include a positive effect on erection quality in men with ischemic heart disease (IHD; Belardinelli, Lacalaprice, Faccenda, Purcaro, & Perna, 2005; Kalka et al., 2013). Considering the above, the authors attempted to answer the question whether endurance training intensity and training-induced chronotropic response are linked with a change in erection severity in men with IHD and ED.
Material and Method A total of 150 men treated for IHD (107 percutaneous coronary intervention, 43 coronary artery bypass graft), who scored ≤21 points in the initial IIEF-5 (International Index of Erectile Function) test were analyzed. The study group consisted of 115 patients (mean age 62.12 ± 8.71 years) who were subjected to a CR Phase 3 program. The control group consisted of 35 patients (mean age 61.43 ± 8.68 years) who were not subjected to CR Phase 3 program. Because of the documented beneficial influence of CR, no typical randomization was performed (Piepoli et al., 2014). To intentionally prevent the subjects from participating in CR would have been unethical. The authors tried to enroll as many participants as possible. However, some of the approached patients were reluctant and did not agree to participate. The patients who were reluctant to participate gave distance from the facility and the bother of having to attend exercises daily as reasons of their refusal. Thus, the great disproportions in the volume of the study groups. The two groups were statistically equivalent on all outcomes and potential covariates with the exception of Left ventricular end-diastolic dimension (LVEDD; Table 1). All patients gave their informed content to the study and completed the initial and final IIEF-5 tests fully (all categories). For patients from the study group, an inclusion criterion for the study was participation in at least 90% of exercises during the CR program.
Table 1. Inclusion Criteria. Basic inclusion criteria 1. No previous history of clinically significant pulmonary disease 2. Absence of any severe pelvis and vertebral column injury 3. No significant deviations in the initially performed resting spirometry test 4. Absence of any neurological and orthopedic disorders 5. No clinical symptoms of thyroid gland disorders 6. Absence of any stenocardial symptoms provoked by the cardiac training. 7. No hormonal treatment 8. Absence of any anatomical changes in penis; no benign prostatic hyperplasia; no prostate cancer 9. No repair surgery on abdominal aorta and/or iliac arteries 10. No psychiatric treatment and no antidepressant usage 11. Laboratory tests: (a) no anemia; (b) no deviations from the norm in thyrotropic hormone plasma levels
All patients were married and had the same sex partner for a long time. The inclusion criteria are given in Table 1. In all patients from the study group and the control group, a pharmacological treatment as per IHD treatment standards was applied. The treatment for IHD also included nonpharmacological protocols aimed at eliminating IHD risk factors, in particular at introducing prohealth physical activity and pharmacological treatment employing the use of acetylsalicylic acid and/or other antiplatelet drugs, IHD medication (short-acting nitrates, beta-adrenergic blocking agents, calcium antagonists), and hypolipidemic agents (statins, fibrates). As a result of concurrence of arterial hypertension, angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARBs), and diuretics were administered (Jankowski et al., 2013). The criterion for exclusion of a patient from the study was a necessary dosage adjustment of drugs with a proven negative effect on erection and of drugs affecting the chronotropic reaction, carried out during the 6-month study. The inclusion and exclusion criteria were assessed by a therapeutic team in charge of CR (one internal diseases specialist, one cardiologist, and two physiotherapists). The participants’ case histories and results of additional tests were analyzed. If case of doubt, additional specialists were invited to consult. All respondents were informed of the study procedure and the key aspects of the studied issue and have given their written informed consent. There were no severe ventricular arrhythmias or conduction disturbances found in any of the patients in a 24-hour electrocardiograpic monitoring (Holter monitor).
Downloaded from jmh.sagepub.com at FLORIDA STATE UNIV LIBRARY on September 29, 2014
3
Dariusz et al. Table 2. Clinical Characteristics of the Study Groups (Patients With IHD and ED). Specification Numerical amount Age in years, mean ± SD BMI in kg/m2, mean ± SD Myocardial infarction, n (%) Hb concentration in g%, mean ± SD eGFR (MDRD), mean ± SD TC in mg%, mean ± SD TG in mg%, mean ± SD LDL-C in mg%, mean ± SD HDL-C in mg%, mean ± SD Echocardiography parameters, mean ± SD LVEDD in mm EF in % LA in mm RVEDD in mm IHD treatment, n (%) PTCA CABG Drugs, n (%) Beta-blockers ACEI/ARBs Statins/fibrats Diuretics Cardiovascular risk factors, n (%) Hypertension Diabetes type 2 Lipid disorders Smoking habits BMI ≥25 kg/m2 Inadequate leisure time physical activitya
Study group
Control group
p value
115 62.12 ± 8.75 28.67 ± 4.67 78 (67.83) 14.43 ± 0.91 77.23 ± 10.79 212.79 ± 46.03 173.89 ± 104.57 123.66 ± 39.20 48.48 ± 14.52
35 61.43 ± 8.81 27.08 ± 2.43 19 (54.29) 14.60 ± 0.79 81.03 ± 11.90 214.60 ± 41.10 169.07 ± 77.42 136.32 ± 39.03 46.73 ± 11.56
.6827 .0557 .2057 .3137 .0766 .8344 .8014 .1227 .5403
52.51 ± 5.72 56.75 ± 7.47 37.88 ± 3.97 23.00 ± 4.14
55.49 ± 3.72 54.97 ± 7.18 38.66 ± 3.49 24.31 ± 1.95
.0044* .2161 .2977 .0719
80 (69.57) 35 (30.43)
27 (77.14) 8 (22.86)
110 (95.65) 81 (70.43) 105 (91.30) 27 (23.47)
33 (94.29) 28 (80.00) 28 (80.00) 6 (17.14)
.5127 .5127 .6652 .3707 .1229 .5760
72 (62.61) 24 (20.86) 75 (65.22) 66 (57.39) 85 (73.91) 113 (98.26)
26 (74.29) 9 (25.71) 22 (62.86) 20 (57.14) 22 (62.86) 35 (100.00)
.2854 .7093 .9571 .8657 .2923 .9999
Note. IHD = ischemic heart disease; BMI = body mass index; Hb = hemoglobin; TC = total cholesterol; eGFR = estimated glomerular filtration rate; MDRD = modification of diet in renal diseases; TG = triglyceride; LDL-C = low-density lipoprotein; HDL-C = high-density lipoprotein; LVEDD = left ventricular end-diastolic dimension; EF = ejection fraction; LA = left atrial dimension; RVEDD = right ventricular end-diastolic dimension; PTCA = percutaneous transluminal coronary angioplasty; CABG = coronary artery bypass graft; ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blockers; CVD = cardiovascular disease. a. Inadequate physical activity means
