IJCS | Volume 32, Nº4, July/August 2019

422 Gonzáles et al. Exercise and erectile dysfunction in heart Int J Cardiovasc Sci. 2019;32(4):418-427 Review Article Questionnaire” was used by Belardinelli et al., 25 and the International index of erectile function (IIEF) in the studies by Sties et al., 26,40 Belardinelli et al., 25 investigated only married patients, while in the studies of Sties et al., 26,40 individuals with an active sex life were evaluated regardless of marital status or monogamy. Regarding EF, the study by Belardinelli et al., 25 showed that the exercise group with an intervention of 8 weeks demonstrated a significant improvement in the quality of the erection and in the relationship with the partner. In the study by Sties et al., 26 the EF domain showed significant improvement after 12 weeks of intervention. In the study by Sties et al., 40 the significant improvement in the EF score was evidenced only in the group submitted to high-intensity physical exercise training. However, when the results related to the EF classification were verified, both individuals submitted to both high-intensity and moderate training showed significant score increases. Functional capacity In the cardiopulmonary test, Belardinelli et al., 25 and Sties et al., 26 demonstrated a significant improvement in VO 2 peak. In the study by Sties et al., 40 the improvement in VO 2 peak was evidenced only in the high-intensity interval exercise group. Only in the study by Sties et al., 26 the six-minute walk test (6MWT) was used and verified that all individuals showed a significant improvement in the walked distance after the intervention. Endothelial function Regarding the endothelial function results, only two studies 25,40 performed the evaluation of this variable. In the study by Belardinelli et al., 25 it was possible to observe a significant improvement in the flow-mediated dilation (FMD) of the brachial artery in the group submitted to physical exercise for 8 weeks, at the same time that the FMDwas the strongest independent factor of improvement of the sexual function in these patients. For Sties et al., 40 FMD of the brachial artery did not show a significant improvement in any of the study groups (moderate and high-intensity) after 12 weeks of intervention. Quality of life Assesment of quality of life was performed in two of the three analyzed studies. 25,40 Both studies used the Minnesota Living with Heart Failure (MLHFQ) questionnaire, validated for patients with HF. There was a significant improvement in the QoL score after physical exercise training in different intensities (high and moderate). Evaluation of methodological quality The eligible studies were fully read and scored based on (Table 2) a structured spreadsheet for data extraction previously designed for the study. Of the three studies analyzed, two 25,40 got the maximum scale score (12 points) (Table 2), showing good methodological quality. Only one study showed a low score of 6 points, due to its design nature (uncontrolled, non-randomized longitudinal clinical trial). 26 The lack of intention-to-treat analysis was verified in all studies, indicating a methodological limitation. Discussion All studies from this review evaluated sexual function through validated and self-reported questionnaires. Physical exercise led to improvements in EF regardless of the degree of dysfunction. Sexual dysfunction is an increasingly common problem in the middle-aged world population, strongly associated with cardiovascular disease. 5,8,15 Its high prevalence in HF patients is understandable, since SD andHF have common risk factors and pathophysiological characteristics. 3 Also, some drugs used in the treatment of HF seem to impair sexual function. 41 Between 58% and 87% of patients report problems in sexual function after the diagnosis of HF. 12,42,43 These problems may vary from a decrease in the interest and frequency of sexual activity to total abstinence, reported by 25%of these individuals. 13 Despite the high prevalence of SD in subjects with HF with concomitant worsening in the QoL indexes, few studies or relevant data on the topic 44 have been published. In this context, ED stands out as the most prevalent sexual alteration in patients withHF 3,14,15 and it influences not only the QoL but also the prognosis and the survival. 9 of these patients. Therefore, it is imperative that health professionals do not neglect this condition, and be prepared to discuss sexual function with patients and their partners, providing themwith adequate counseling and pertinent information. 13,41,42,45 According to the