IJCS | Volume 32, Nº4, July/August 2019

424 Gonzáles et al. Exercise and erectile dysfunction in heart Int J Cardiovasc Sci. 2019;32(4):418-427 Review Article Table 2 - Studies classification according to the Testex scale (maximum score of 15 points) TESTEX Items Authors Belardinelli et al (2005) 25 Sties et al (2013) 26 Sties et al (2014) 40 1 – Eligibility criteria specified Yes Yes Yes 2 – Randomization specified Yes Not Yes 3 – Allocation concealment Yes Not Yes 4 – Groups similar at baseline Yes Not Yes Blinding of all participants* Not Not Not Blinding of all therapists* Not Not Not 5 – Blinding of assessor (for at least one key outcome) Not Not Not 6 – Outcome measures assessed in 85% of patients# Yes Yes Yes 7 – Intention-to-treat analysis Not Not Not 8 – Between-group statistical comparisons reported a Yes Not Yes 9 – Point measures and measures of variability for all reported outcome measures Yes Yes Yes 10 – Activity monitoring in control groups Yes Not Yes 11 – Relative exercise intensity remained constant Yes Yes Yes 12 – Exercise volume and energy expenditure Yes Yes Yes Total score TESTEX 12 6 12 Subtitle: * – items of the scale TESTEX that are not scored; #items of the TESTEX scale which scores up to 3 points; ªítems of the TESTEX scale with escores up to 2 points. European Society of Cardiology (Guideline ESC 2016), management of sexual dysfunction of patients with HF should consider the educational status of the patients, who should be informed about sexual behavior, its relationshipwithHF, and how to treat EDwhen it exists. 46 For this purpose, physical exercise should always be recommended. 17-21 According to the results obtained in this systematic review, a physical exercise program is considered effective in the treatment of ED inHF patients, promoting a significant improvement in erectile function scores 25,26,40 and QoL 25,40 in individuals with functional class II and III (NYHA). Studies have shown that physical exercise is a safe and effective therapy for ED, even for patients with more severe impairment, which may be an additional motivation to exercise for HF patients. Although ED treatment in these patients may involve the use of PDE-5 inhibitors, this class of drugs is safe only in patients with functional class I and II (NYHA) and is contraindicated in high-risk patients or patients taking nitrates. 47 In relation to the pathophysiology of ED and HF, two pathways of neurovascular activation have been suggested to be responsible for the association between these conditions. 25,48-51 These pathways would explain the reduced capacity of penile arterial dilation caused by inadequate blood inflow to the corpus cavernosum, making penile stiffening and enlargement impossible for a satisfactory erection in HF patients. This could contribute to the greater activation of the sympathetic nervous system, which would increase smooth muscle