IJCS | Volume 32, Nº4, July/August 2019

425 Gonzáles et al. Exercise and erectile dysfunction in heart Int J Cardiovasc Sci. 2019;32(4):418-427 Review Article tone of the penis and consequent vasoconstriction of the penial vessels. 5,11,48 In this view, we showed that therapies that can modulate neurovascular activation pathways in patients with HF and ED are promising, including physical exercise. By evaluation of endothelial function, the study developed by Belardinelli et al., 25 demonstrated that there was a significantly greater improvement in FMD to the brachial artery in the group of patients with ED submitted to the 8-week exercise protocol compared to controls. In this study, FMD was the strongest independent factor related to the improvement of the sexual function of these patients, who showed a significant improvement in the quality of penile erection. In the study of Sties et al., 40 the FMD of the brachial artery showed no significant change after 12 weeks of intervention. The difference in these results may have occurred due to differences in the methods used for endothelial function evaluation. Belardinelli et al., 25 evaluated FMD by application of 240mmHg of pressure in the cuff for 4.5 minutes in the dominant upper limb of the patient. The measurements were performed after the use of sublingual nitroglycerin, 30s, and 90s after deflation. In the study by Sties et al., 40 the pressure used was 250mmHg, for 5 minutes, in the left upper limb and the image obtained was captured 50 seconds after the deflation. The presence of peripheral hypoperfusion in HF patients with impaired LVEF 3,5,48,52 contributes to aggravate ED, 4,10,11 worsening functional status and exercise tolerance. 5,53-55 The symptoms of HF (dyspnea, fatigue, and exercise intolerance) are among the main factors responsible for impairing sexual function. 5,13 The results of this review demonstrated that physical exercise in different intensities was able to promote significant improvement in functional capacity and tolerance to exercise in patients with HF and ED when evaluated by cardiopulmonary test. In the study by Sties et al., 40 the improvement of exercise tolerance in cardiopulmonary exercise test was evidenced only in subjects submitted to high-intensity interval exercise in comparison to those submitted to moderate-intensity exercise. These findings are in agreement with the studies that recommend the use of high-intensity physical training for patients with HF. 22,24 However, all the patients with ED assessed by the 6MWT showed a significant improvement in the walked distance after the intervention, regardless of exercise intensity. Limitations Among the limitations of this study, there is the small number of participants. Only one study included a physically inactive control group, and only one complete articlewas included in the review. These limitationsmake it difficult to carry out a quantitative analysis and show a large gap in the literature. Additionally, because of the scarcity of data about this relevant topic in the clinical area, further studies should be encouraged to confirm the findings. Conclusion In this systematic review, physical exercise was recommended as a safe and effective therapy to improve EF, endothelial function, quality of life and functional capacity of individuals with ED and heart failure. Author contributions Conception and design of the research: Gonzáles AI, Carvalho T, Andreato LV, Sties SW, Souza AC. Acquisition of data: Gonzáles AI, Carvalho T, Andreato LV, Sties SW, Souza AC. Analysis and interpretation of the data: Gonzáles AI, Carvalho T, Andreato LV, Sties SW, Souza AC. Critical revision of the manuscript for intellectual content :Gonzáles AI, Carvalho T, Andreato LV, Sties SW, Souza AC. Potential Conflict of Interest No potential conflict of interest relevant to this article was reported. Sources of Funding There were no external funding sources for this study. Study Association This article is part of the thesis of doctoral submitted by AnaGonzáles, from Universidade Estadual de Santa Catarina . Ethics approval and consent to participate This article does not contain any studies with human participants or animals performed by any of the authors.