In the present study, 80% of men with systolic heart failure suffered from erectile dysfunction of which 36% had severe erectile dysfunction. This finding is consistent with the results of other studies. In studies conducted by Medina et al.,9
Schwarz et al.10
and Rastogi et al.11
the prevalence of erectile dysfunction in HF patients was found to be 74%, 84% and 75%, respectively. Our findings confirmed that sexual activity is altered in patients with systolic heart failure.
In the current study, statistically significant relationship was found between age and erectile severity. This is in line with the findings of Apostolo et al.16
and Steinke et al.15
which showed a relationship between age and erectile dysfunction in men with systolic heart failure. It is postulated that altered penal vasculature, reduced penile circulation, reduced androgen, reduced smooth myocytes, reduced nitric oxide production are involved in severe erectile dysfunction in the elder patients with HF. Our findings suggested that following a decrease in LV ejection fracton, erectile dysfunction is aggravated in men with systolic heart failure. These are consistent with the findings of Mandras et al.17
and Jaarsma et al.26
that showed sexual desire, sexual function and intercourse are negatively affected by reduced LV ejection fraction. It is estimated that lowered ejection fraction restricts vascular congestion in the penis ultimately leading to erectile dysfunction.
The present study showed that reduced haemoglobin levels are associated with an increase in the severity of erectile dysfunction. This is consistent with the results of Apostolo et al. who demonstrated that blood haemoglobin levels and erectile dysfunction are related in men with HF.16
Anaemia presumably deteriorates erectile dysfunction by reducing tolerance for activity and causing fatigue. In the current study, reduced blood cholesterol level was related to erectile dysfunction. This finding was in agreement with the results of Vrentzos et al.27
and Smith et al.28
who showed that elevated cholesterol levels are related to erectile dysfunction. Findings of another study conducted by Miner and Billups suggested that dyslipidemia and hyperlipidemia enhance vascular disorders related to erectile dysfunction.29
Therefore, improving life style with nutrition, exercise and medications for reducing and monitoring blood cholesterol levels can significantly reduce the severity of erectile dysfunction in men with HF.
In this study, erectile dysfunction was found to be significantly related to education and profession in which the highest rate of erectile dysfunction was found in illiterate and retired subjects. This is consistent with the results of Holden et al. who revealed that demographic and social variables are related to erectile dysfunction.30
Our findings showed that erectile dysfunction was more severe in HF patients who also suffered from kidney disease. This is in line with the findings of Jaarsma who stated that the concurrence of chronic diseases with HF is associated with more severe erectile dysfunction.6
In a study by Makarem et al. the prevalence of erectile dysfunction in men with chronic kidney failure under haemodialysis was reported to be 86.6%.31
In a study by Nassir, 71% of men under dialysis were found to have erectile dysfunction.32
It seems that mental factors, progression of atherosclerosis in kidney disease, hormonal alterations as in hyperprolactinemia, lowered serum testosterone levels and blood pressure controlling drugs all play a role in the aggravation of erectile dysfunction in men with HF along with kidney failure.
Men with systolic heart failure treated with digoxin had more severe erectile dysfunction. This is consistent with the findings of Rastogi et al. who showed that the side effects of certain drugs including digoxin are related to the severity of erectile dysfunction in men with HF.11
A study conducted by Schwarz et al.7
claimed that the use of digoxin was associated with higher incidence of erectile dysfunction with an increase in estrogen levels and decrease in testosterone and luteal hormone following digoxin treatment. Moreover, digoxin inhibits nitric oxide production and impairs smooth muscle function in the vessels.7
In this study, men with HF treated with angiotensin receptor blockers had more severe erectile dysfunction. This was concordant with the results of Rastogi et al.11
However some studies have associated angiotensin receptor blockers and angiotensin converting enzyme inhibitors with improved sexual performance.7
In the current study, men with systolic HF treated with beta blockers had more severe erectile dysfunction. This was similar to the results of Rastogi et al.11
A study performed by Franzen et al. revealed that 31% of cardiovascular patients showed drug related erectile dysfunction following the use of atenolol.35
However, results found by Cruickshank et al. showed that metoprolol and atenolol have no effect on sexual performance.36
In this study HF patients treated with diuretics were found to have more severe sexual dysfunction. This finding was similar to the results of Apostolo et al. who showed a relationship between diuretic consumption and sexual dysfunction.16
Buranakitjaroen et al.37
also revealed that treatment with diuretics in men was a predictor of sexual dysfunction. Basically, drug side effects can affect patient’s adherence to the administered drugs. The present study revealed that male HF patients with more severe sexual dysfunction also suffered from higher degrees of depression. This is consistent with the results of other studies which found depression is related to erectile dysfunction.7
It seems that while depression is associated with lower sexual desire, mental and psychiatric factors could reciprocally affect the emergence of erectile dysfunction in men with systolic HF. This study indicated that men with more severe erectile dysfunction experience a lower quality of life. This is consistent with the findings of Schwarz et al.10
and Freitas et al.40
It appears that sexual performance is an important aspect of life in which its impairment can affect personal relations and mental states in patients with systolic heart failure. The main limitation of this study was the absence of control group. Further studies are needed to determine the prevalence of erectile dysfunction in men with diastolic heart failure. This study was part of a research project with the code 1/11972.
In conclusion, erectile dysfunction was prevalent in patients with systolic heart failure and it was related to factors such as age, occupation, education, left ventricular ejection fraction, haemoglobin and cholesterol levels, kidney disease, medications, depression and quality of life.