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Sildena l is the rst oral treatment for ED and the most extensively evaluated [28] Overall success rates in patients with cardiovascular disease of 80% or greater have been recorded with no evidence of tolerance Patients with diabetes with or without additional risk factors, with their more complex and extensive pathophysiology, have an average success rate of 60% In randomized trials to date, open-label or outpatient monitoring studies, the use of sildena l is not associated with any excess risk of myocardial infarction, stroke, or mortality [29,30] In patients with stable angina pectoris there is no evidence of an ischemic effect due to coronary steal, and in one large, double-blind, placebo-controlled, exercise study sildena l 100 mg increased exercise time and diminished ischemia [31] A study of the hemodynamic effects in men with severe CAD identi ed no adverse cardiovascular effects and a potentially bene cial effect on coronary blood ow reserve [32] Studies in patients with and without diabetes have demonstrated improved endothelial function acutely and after long-term oral dose administration, which may have implications beyond the treatment of ED [25] Sildena l has also been shown to attenuate the activation of platelet IIb/IIIa receptor activity [33] Hypertensive patients on mono- or multiple therapy have experienced no increase in adverse events with the exception of doxazosin, a non-selective -adrenoceptor antagonist Occasional postural effects have occurred with sildena l when taken within four hours of doxazosin 4 mg; an advisory to avoid this time interval is now in place Sildena l has also been proven effective in heart failure patients who were deemed suitable for ED therapy [34] The incidence of ED in heart failure patients is 80%, making this nding of major clinical importance On average, the sildena l dose is 50 mg with 25 mg advised initially in those over 80 years of age because of delayed excretion Sildena l 100 mg is invariably needed in patients with diabetes An empty stomach and avoiding alcohol or cigarette smoking facilitates the effect Sildena l.

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Trying to get the best possible deal on your insurance policies Insurance premiums vary from policy to policy and situation to situation The rate you pay will reflect the insurance company s assessment of the risks you face, such as the age of the property, location, crime statistics for the area, and other factors Always compare and get written quotes from at least three insurance brokers for any type of insurance you are considering Also, ask about obtaining discounts, each of which could range from 5 to 10 percent off the original premium You could use several of them, but most insurance companies don t allow the aggregate amount of discounts to exceed 50 percent of the original premium Common types of discounts given for property insurance coverage may be available if you have No claims in the previous five years, or at all A mortgage-free discount Three or more years standing as a client A Block Watch or similar volunteer monitoring program in your community Eligibility for an age-related discount for property owners over the age of 65, and sometimes as young as 50 A new home ten years old or less (this may result in a depreciated premium discount based on the home s age) A monitored fire and burglar alarm in place Local alarm systems (not monitored) Different types of insurance products with the same insurance company or broker (may result in a multi-line discount)

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Cardiovascular Issues in Male and Female Sexual Dysfunction 100 mg has no additional adverse cardiac effects above the 50 mg dose and should be routinely prescribed if the 50 mg dose is not effective after four attempts Sildena l s short half-life makes it the drug of choice in patients with the more severe cardiovascular disease, allowing early use of support therapy if an adverse clinical event occurs

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The use of testosterone replacement therapy for the treatment of hypogonadism and ED may assist PDE5 inhibitors if they have failed to be effective [39] Testosterone levels within the normal range have neutral or potentially bene cial effects on the cardiovascular system [40] Androgen replacement therapy should be offered to men with CAD and hypogonadism if symptomatically appropriate [3] The absence of long-term studies needs to be addressed in terms of possible preventive properties on the vascular wall, reduction in low-density lipoprotein levels and the reduction of insulin resistance in contrast to the increase in hematocrit and risk of exacerbating prostate cancer [3,40]

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Tadala l has also been extensively evaluated in patients with cardiovascular disease and has a similar safety and ef cacy pro le to sildena l [35] Studies have shown no adverse effects on cardiac contraction, ventricular repolarization, or ischemic threshold A similar hypotensive effect has been recorded with a dose of doxazosin of 8 mg, so caution is needed As hypotension does not occur in the supine position, and as tadala l has a long half-life, it is suggested that tadala l is taken in the morning and doxazosin in the evening There is no interaction of tadala l with the selective -adrenoceptor antagonist tamsulosin which can, therefore, be prescribed as an alternative to doxazosin for benign prostate hypertrophy [36] Because of its long half-life, tadala l may not be the rst choice for patients with more complex cardiovascular disease However, as 80% of patients with cardiovascular disease stratify into low risk it is an alternative for the majority

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