If you’ve received a diagnosis of erectile dysfunction (ED) and have a heart condition, you might be wondering which ED treatments are safe and effective.

There are currently several treatments available for ED. Many of the first- and second-line treatments used for ED are also appropriate for people who have heart disease.

This is great news, since complaints of ED are common in people who have cardiac conditions.

In fact, Dr. Joel Kahn, a cardiologist and the director of the Kahn Center for Cardiac Longevity, says the complaints often precede the diagnosis of heart disease by a number of years, and an opportunity is missed for earlier heart diagnosis and treatment.

“The complaint should lead to an assessment of all traditional measures like adequacy of blood pressure control, blood glucose control, blood cholesterol control, smoking, diet, and fitness as well as labs to evaluate these issues, testosterone levels, and thyroid hormone levels,” he said.

Here’s an overview of the ED treatments that are safe and effective for people with heart disease.

Several lifestyle factors can have a positive outcome for both ED and heart disease. Your doctor may talk to you about certain habits you should quit, like smoking, or habits you can implement, like exercise.

Kahn says the first safe ED treatment for people with heart disease is to look at their lifestyle.

“Some patients regain their sexual function by improved diets focusing on whole plant selections, gradual increases in fitness activities, quitting smoking, weight reduction, and better sleep therapies,” he said.

There are day-to-day changes that can help improve your heart health as well as manage ED.

Activities that are good for ED and your heart

  • Eat a heart-healthy diet with an emphasis on fruits, vegetables, whole grains, healthy fats, and lean protein.
  • Get regular exercise that includes cardiovascular activities, resistance training, and mindfulness-based exercise like yoga.
  • Reduce or eliminate alcohol use.
  • If you smoke or use other substances, quit. Support is available. Your doctor can help you outline a plan.
  • If needed, lose weight or manage your current weight.
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The American Urological Association recommends a referral to a mental health professional to help you:

  • bridge the gap between treatment and your sexual relationships
  • promote continuing your treatments
  • reduce performance anxiety

The focus of counseling sessions will be helping you reduce anxiety about sexual situations and improve communication between you and your sexual partner about any sexual concerns.

You can also discuss ways to include ED treatments into your sex life.

Oral medications that include phosphodiesterase type 5 (PDE5) inhibitors are the first-line treatment for ED, according to a 2016 research review.

The most common are sildenafil (Viagra) and tadalafil (Cialis). Other oral medications include vardenafil HCL (Levitra) and avanafil (Stendra).

These four PDE5 inhibitors are the only oral medications approved in the United States by the Food and Drug Administration (FDA) to treat ED.

After lifestyle modifications, Kahn says PDE5 inhibitors are the second approach to ED treatment.

“They are generally safe to use in stable heart patients not taking nitroglycerin medication, if the extent of their heart disease is known and if they have at least average fitness and stability,” he said.

Taking certain PDE5 inhibitors like sildenafil alongside nitroglycerin-based medications (nitrates) is contraindicated, meaning they shouldn’t be used together. Using them together can result in severe low blood pressure (hypotension) and death, according to a 2018 research review.

“Men on nitroglycerin medications with poor fitness, with unstable symptoms, and not fully evaluated should not be treated with these medications,” Kahn said.

Moreover, in some people with heart disease, Kahn recommends performing a treadmill stress test before prescribing medication.

Treadmill tests also help determine whether you’re healthy enough for sexual activity, since this often involves physical effort and increasing your heart rate.

Q. What are examples of nitrate medications?

A. “Medications like Imdur, Isordil, nitroprusside are all blood pressure medications based on organic nitrates. These medications should not be used in conjunction with PDE5 inhibitors.

“Many patients with prior history of angina [chest pain] may have nitroglycerin listed as a medication, but if they haven’t used the medication in a long time, they may be able to use PDE5 inhibitors. It is most important that these situations be cleared by the patient’s cardiologist prior to prescribing.”

— Joseph Brito, MD

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Alprostadil is a drug that increases blood flow by expanding blood vessels. When injected into the penis, it increases blood flow to the penis, encouraging an erection.

It’s considered a self-injection therapy, meaning you or your partner can learn to inject it into the side of the penis.

This is an option for treating ED if oral drugs don’t work, have too many side effects, or can’t be used because they may interact with other medications.

If low testosterone levels and low sex drive are factors in your ED, your doctor may recommend testosterone therapy in combination with a PDE5 inhibitor.

Experts also note that addressing low testosterone on its own isn’t always enough to improve ED, so working with ED-specific treatments can help.

A vacuum erectile device with constricting ring (aka a penis pump) is a pump that helps you get and maintain an erection.

For the most part, penis pumps are safe, well tolerated, effective, and have high reported satisfaction rates.

In general, doctors can recommend a penis pump as a first-line treatment for ED for their patients who have heart disease. These devices can also be used with oral medications when appropriate.

A penile implant is the primary surgical treatment for ED. There are two types of penile implants:

  1. an inflatable penile prosthesis (IPP), which can be physically adjusted to fill the IPP and make the penis erect
  2. a malleable prosthesis, semirigid rods that stay the same firmness all the time and can be bent to desired position for use

The main benefit of this treatment is the ability to generate an erection for as long and as frequently as desired.

In general, a penile implant is a safe third-line treatment for ED in people with heart disease.

That said, it’s often only recommended for people who are fit for surgery and can’t use oral medication, injections, or penis pumps.

Is ED common after getting a heart stent?

“Yes, ED is common in men being treated with stents in their heart arteries for advanced heart blockages,” Kahn said.

Sometimes ED is an earlier sign of heart disease

In fact, if you ask men about ED at the time of their stent placement, Kahn says you’ll often learn that they’ve had issues for years with sexual performance that wasn’t recognized as a risk factor for heart disease, and the opportunity for earlier diagnosis was lost.

Kahn says men who are getting stents often have:

  • high cholesterol
  • diabetes mellitus
  • high blood pressure
  • poor diet
  • low physical activity

“This leads to heart disease and ED. The risk factors are identical,” he said.

Other reasons for experiencing ED after having a heart stent put in place include medications and depression.

Medications after stent placement can cause ED

Some people take beta-blockers for continued treatment after getting a heart stent. A common side effect from these medications is sexual dysfunction due to changes in blood pressure and heart rate.

ED from beta-blockers can be reversible when the medication is stopped.

Depression and antidepressants can affect sex drive

Many people who have had a heart stent placed also experience depression. Depression is associated with low libido, or sex drive. Additionally, antidepressant medications can also lead to ED.

Why is it common for people experiencing congestive heart failure to also have ED?

Chronic heart disease is common with other medical conditions that can also cause ED

Many people living with chronic heart disease have other health conditions as well, each of which can cause ED on their own.

Chronic heart disease is associated with poor blood flow in the body

For some people who have had heart attacks, they’ve been experiencing blocked smaller arteries for some time and may have had trouble with getting or maintaining an erection as a result of poor blood flow to the penis.

Dr. S. Adam Ramin, a urologic surgeon and medical director of Urology Cancer Specialists, says that for a person to get a strong, stiff erection, their arteries must be in tip-top shape.

“But, unfortunately, as the arteries become clogged, flow decreases, and there is not enough blood flowing into the erectile bodies of the penis to get a successful erection,” he said.

“ED can become even worse with a failing heart since, in addition to the underlying vascular problems, a failing heart will not be able to pump adequate blood to the penis,” Ramin said.

Common blood pressure medications

Treatment for heart failure often includes beta-blockers, which manage heart rate and blood pressure. One of the possible side effects of these medications is sexual dysfunction.

Is ED a sign of heart disease?

ED can be a sign of heart disease, yes. Those with an ED diagnosis are at higher risk for cardiovascular disease, coronary disease, and stroke.

ED and heart disease also share many of the same modifiable risk factors, such as:

  • smoking
  • poor diet
  • diabetes
  • high blood pressure
  • sedentary lifestyle

An older 2011 research review found that ED is likely an independent risk factor for cardiovascular disease.

More recently, the American Heart Association says results from a 2018 study found that ED is associated with a twofold increase in heart attacks, strokes, and cardiovascular death beyond traditional risk factors.

Building from that research, preliminary results from a 2019 study found that even after adjusting for shared risk factors, men with ED were 66 percent more likely to receive a diagnosis of atrial fibrillation, or irregular heartbeat.

Although future research is needed, the study authors point out that “if a patient has ED, physicians should investigate other cardiovascular risk factors and initiate treatment as soon as possible.”

There are a number of treatments that help with ED and are safe for you to try when you have a heart condition.

Lifestyle changes are a great place to start. What you do on a regular basis, like being active during the day, can improve erectile function and benefit other aspects of your health.

Whether you take medication for ED, are considering surgery, or making changes to your lifestyle, talking with a mental health professional can also help you with your health and relationships.

If you have a heart condition or heart disease, consulting with cardiology and urology healthcare providers is important to develop a safe treatment plan.