To the Editor: Dr Arruda-Olson and colleagues1 found that sildenafil had no effect on symptoms,
exercise capacity, or ischemia in men with known or probable coronary artery
The authors' model of reversible myocardial ischemia has important clinical
limitations. The great majority of serious cardiac events related to sexual
activity—with or without sildenafil—are destined to occur not
in patients with inducible ischemia caused by obstructive coronary lesions,
but rather in patients who experience rupture of vulnerable but nonobstructive
coronary lesions.2 Many such individuals
also have diabetes, hyperlipidemia, and hypertension and use tobacco, which
are themselves risk factors for erectile dysfunction, yet these patients do
not exhibit inducible ischemia.3 This study
was not designed to address this important group.
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