Patients often express concerns that medications given to treat symptoms or reduce cardiovascular risk could cause erectile dysfunction. Although these perceptions are often firmly and widely held, studies and reviews have not delin- eated a clear association between these drugs, including beta blockers, and sexual dysfunction.488 492 A related issue that could arise is use of phosphodiesterase 5 inhibitors, such as sildenafil, vardenafil, or tadalafil, to improve erectile function. Although, as discussed in the section on treatment of SIHD, current evidence has shown that these drugs do not raise the risk of adverse cardiovascular events in men with SIHD,493,494 there is a clear risk of serious hypotension when they are taken in conjunction with nitrates, and the combination is absolutely contraindicated. There are also potential drug drug interactions with alpha-blockers that are sometimes used to treat hypertension.495 4.4. Guideline-Directed Medical Therapy 4.4.1. Risk Factor Modification: Recommendations 4.4.1.1. Lipid Management Class I 1. Lifestyle modifications, including daily physical ac- tivity and weight management, are strongly recom- mended for all patients with SIHD.18,496 (Level of Evidence: B) 2. Dietary therapy for all patients should include re- duced intake of saturated fats (to <7% of total calories), trans fatty acids (to <1% of total calories), and cholesterol (to <200 mg/d).18,497 500 (Level of Evidence: B) 3. In addition to therapeutic lifestyle changes, a mod- erate or high dose of a statin therapy should be prescribed, in the absence of contraindications or documented adverse effects.18,398,400,458,501 (Level of Evidence: A) Class IIa 1. For patients who do not tolerate statins, LDL cho- lesterol lowering therapy with bile acid seques- trants,* niacin, or both is reasonable.502,504,505 (Level of Evidence: B) Epidemiological studies have established serum cholesterol as an important coronary heart disease risk factor. 