Effects of short-term moderate exercise training on sexual function in male patients with chronic stable heart failure

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Abstract

Background

Patients with chronic heart failure (CHF) have sexual dysfunction that impairs quality of life. Recent trials have demonstrated that exercise training (ET) improves quality of life (QOL) of CHF patients, but it is not established whether this benefit may be associated with an improvement in sexual dysfunction.

Objective

To determine whether ET can improve sexual dysfunction in patients with CHF.

Methods

We prospectively studied 59 male patients (57±9 years) with stable CHF in sinus rhythm and without prostatic disease. Patients were randomized into two groups. A group (T, n=30) underwent supervised cycle ergometer ET at 60% of peak VO2, three times a week, 60 min each session, for 8 weeks. A group (NT, n=29) was not exercised. Medications were not changed during the study. On study entry and at 8 weeks all patients underwent a symptom-limited cardiopulmonary exercise testing, brachial artery endothelium-dependent (ED) and endothelium-independent (EI) vasomotor responses, QOL and sexual activity profile assessment (SAP) by questionnaire.

Results

At 8 weeks, no changes were observed in control patients. In trained patients, however, peak VO2 improved by 18% (P<0.005) and was correlated with QOL (r=0.80; P<0.001). Flow-mediated dilation improved in trained patients (from 2.29±1.13% to 5.04±1.7%, P=0.0001), while EI dilation (after 0.3 mg sublingual NTG) did not. In group T, all three domains (i.e. Domain 1=relationship with the partner; Domain 2=quality of penile erection; Domain 3=personal wellness) were significantly improved from baseline (total score patients: from 3.49±3.4 to 6.17±3.2, P<0.001; partners: from 2.47±2.7 to 4.87±2.5, P<0.001). Pre-post training change in SAP total score was correlated with changes in coronary risk profile (r=−0.49; P=0.01), peak VO2 (r=0.67; P<0.001) and QOL (r=0.73; P=0.01). Multivariate analysis selected the improvement in ED-vasomotor response as the strongest independent predictor of SAP improvement (r=0.63, P<0.001).

Conclusions

In stable CHF, cycle ergometer ET significantly improves brachial artery endothelial dysfunction, suggesting a systemic effect of leg exercise. This benefit was correlated with improvements in sexual activity.

Introduction

Sexual dysfunction frequently occurs in cardiac patients and its pathophysiological mechanism is not fully understood [1], [2], [3], [4]. A vascular or neurological impairment for penile erection is frequently coupled with psychological and relational problems [5], [6], [7]. Perception of well being and self-esteem are generally depressed and contribute to worsen quality of life (QOL).

One hypothesis is that a depressed sexual activity is caused by endothelial dysfunction. As a matter of fact, erectile dysfunction frequently occurs in patients with one or more coronary risk factors who do not have yet clinical manifestations of coronary artery disease [8], [9], [10], [11], [12]. It is well known that hypercholesterolemia, hypertension, cigarette smoking and diabetes are not only established risk factors for atherosclerosis and premature coronary artery disease, but they are also known to impair endothelial function [13], [14], [15]. Thus, there are similarities between risk factors for coronary artery disease and risk factors for erectile dysfunction, suggesting a common pathophysiological background [16]. Nitric oxide activity may be a possible common link between the two abnormalities, and therapeutic strategies aiming to improve endothelial dysfunction may positively affect penile erection. There is evidence that an increased nitric oxide synthase activity generally translates into enhanced erectile function [17], [18], [19], [20], [21], [22], [23]. However, information is lacking about sexual activity in patients with chronic heart failure (CHF) and whether an improvement in endothelial function may be associated with a more active sexual behaviour.

Chronic heart failure is a complex pathophysiological syndrome characterized by reduced exercise tolerance which is partly related to endothelial dysfunction [24]. Recent evidence is mounting that moderate aerobic exercise training (ET) attenuates endothelial dysfunction in clinically stable chronic heart failure patients, and this effect is correlated with improved functional capacity [25], [26]. This benefit is in part related to improvement in coronary risk profile. However, it may also be the consequence of a direct effect of exercise training on the nitric oxide pathway [27]. Thus, if endothelial dysfunction plays an important role in both chronic heart failure and erectile dysfunction, it is conceivable than an improvement in the endothelium-dependent (ED) vasorelaxation can exert positive effects in both conditions. Therefore, we hypothesize that exercise training, by improving endothelial function, may enhance not only functional capacity, but also sexual activity and quality of life in men with stable chronic heart failure.

Section snippets

Methods

We longitudinally studied 59 male patients with chronic heart failure in stable condition in the last 3 months. (Table 1) The majority of the population study had an ischemic cardiomyopathy with depressed left ventricular function and multivessel coronary artery disease. Inclusion criteria were stable chronic heart failure, absence of prostatic disease, a woman partner, ability to exercise. Exclusion criteria were unstable angina, recent acute myocardial infarction, decompensated heart failure,

Statistical analysis

We used nonparametric statistics for intergroup (Mann–Whitney rank sum test) and intragroup (Wilcoxon signed test) comparisons. Univariate analysis with changes in sexual activity profile as dependent variable was performed to determine the strongest independent predictor variables. The correlations with the most significant coefficients were then entered into a stepwise multiple regression model in order to identify the best independent predictor(s) of sexual activity profile change. To verify

Results

All patients completed the protocol. The compliance rate with training was 88%.

Discussion

This is the first demonstration that short-term moderate intensity aerobic exercise training improves sexual activity in men with stable chronic heart failure. This effect was correlated with improvements in functional capacity and quality of life, and was not influenced by medications. In particular, patients taking oral nitrates had no hypotension or other adverse events during training, and also had similar improvements after training as those who did not receive nitrates. Multivariate

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      Sensitivity analysis to examine the effects of brachial artery FMD from 11 studies [35–38,41,43–46,48,49] and radial artery FMD from five studies [12,39,40,42,47] indicated significant improvement in both, SMD 0.80 (95% CI 0.36 to 1.23, p = 0.0003) (Supplementary Fig. S1) and SMD 1.65 (95% CI 1.06 to 2.23 P < 0.00001) in brachial and radial artery respectively (Supplementary Fig. S2). In each of the studies that administered NTG, a similar degree of vasodilation occurred in exercise and controls and pooled data of nine studies [12,35–37,40–44] indicated that exercise training did not have a significant effect on the endothelial-independent response, SMD -0.15 (95%CI -0.79 to 0.49, p = 0.64) (Supplementary Fig. S3). Pooled data from three studies [39,47,48] showed a significant improvement in CD34+/KDR+ as a result of exercise training, SMD 0.91 (95% CI 0.30 to 1.52, p = 0.003) (fig. 3).

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