Grade of risk | Criteria |
CAVEATS | Phosphodiesterase-5 inhibitors contraindicated with any nitrate preparation should not be taken with alpha-blocking agents |
Nitrates should not be administered within 24 hours (or longer in patients with renal or hepatic dysfunction) of sildenafil, 24 hours of vardenafil, or up to 48 hours of tadalafil |
Low risk | No symptoms and less than three major cardiovascular risk factors (excluding gender) |
Controlled hypertension |
Mild, stable angina |
Post-successful coronary revascularization |
Uncomplicated MI more than six to eight weeks previously in patients who do not have exercise-induced ischemia or who have undergone coronary revascularization |
Mild valvular disease |
Asymptomatic LV dysfunction |
Management |
Patients at low risk can safely initiate or resume sexual activity and can be treated for sexual dysfunction |
Intermediate or indeterminate risk | No symptoms and three or more major cardiovascular risk factors (excluding gender) |
Moderate, stable angina |
Recent MI (more than two but less than six weeks previously); in patients who have not undergone revascularization, the risk can be assessed with stress testing |
Asymptomatic LV dysfunction with LV ejection fraction <40 percent or NYHA class II heart failure |
Noncardiac sequelae of atherosclerotic disease, such as peripheral vascular disease or prior stroke or transient ischemic attack |
Management |
Patients at intermediate or indeterminate risk should undergo further cardiologic evaluation, such as stress testing (particularly in patients with a sedentary lifestyle), in an attempt to restratify the patient into the high risk or low risk category |
High risk | Unstable or refractory angina |
Uncontrolled hypertension |
NYHA class III/IV heart failure |
MI within the past two weeks |
High-risk arrhythmias |
Obstructive hypertrophic cardiomyopathy |
Moderate to severe valvular disease, particular aortic stenosis |
Management |
Patients at high risk should be stabilized by appropriate therapy before resuming sexual activity |