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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 disease (CAD).

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.

Perhaps future research will clarify what levels of functional capacity and severity of ischemia can be considered truly safe for men with CAD who wish to use sildenafil. In the meantime, . . . [Full Text of this Article]

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