How To Evaluate Cardiovascular Risk in a Patient With Erectile Dysfunction


Cardiovascular disease is a leading cause of death and disability in men. Erectile dysfunction, a common problem in men as they age, may also help drive them to seek medical attention in the absence of other cardiovascular symptoms. The link between erectile dysfunction and cardiovascular disease, while now well established, has been previously characterized primarily by shared risk factors.1-4 A number of risk factors are shared by erectile dysfunction and cardiovascular disease, including age,5 sedentary lifestyle, obesity, smoking, hypercholesterolemia, metabolic syndrome,6 insulin resistance,7 hypertension,8,9 and diabetes.8 The common pathophysiologic bases for erectile dysfunction and cardiovascular disease are believed to include endothelial dysfunction,10 inflammation,11 and low testosterone.10,12 The most common organic (medical) etiology of erectile dysfunction is vasculogenic. Numerous studies in men with clinically evident cardiovascular disease have established erectile dysfunction as an independent risk marker for cardiovascular disease4,13 and shown that erectile dysfunction frequently precedes coronary artery disease,14-17 peripheral arterial disease,18 and stroke.15 Erectile dysfunction symptoms appear approximately two to five years before the onset of cardiovascular symptoms,14,19-21 and more severe erectile dysfunction has been correlated with greater atherosclerotic burden;17 extent of coronary artery disease;14,22 and risk of coronary artery disease,15,16 peripheral artery disease,18 and major cardiovascular events.23

An emerging paradigm indicates that erectile dysfunction is in fact an independent marker of cardiovascular disease risk.4 Thus, the presence of erectile dysfunction may provide the opportunity for cardiovascular disease risk mitigation in men with otherwise unrecognized cardiovascular disease. The importance of evaluating cardiovascular risk in men with erectile dysfunction is now a critical factor for overall early stage management of cardiovascular disease, especially in younger men (aged 30 - 60 years). This brief article focuses on the evaluation of cardiovascular risk in men with erectile dysfunction but no known cardiovascular disease.

Recommendations for Evaluation of CV Risk in Men With Erectile Dysfunction but No Known CVD

Erectile dysfunction is now a well-established, independent marker for cardiovascular disease risk,4 and all men should be questioned about their sexual history and functioning as part of the initial assessment of cardiovascular disease risk. Initial inquiry for erectile dysfunction can be done by asking a simple question such as "Have you noticed any change over the past month in your ability to get or maintain a rigid erection suitable for satisfactory intercourse?" Another option is to use a short scored validated questionnaire such as the Brief International Index of Erectile Function (IIEF-5) to assess for erectile dysfunction severity.24 For all men with erectile dysfunction, particularly those with vasculogenic erectile dysfunction, initial risk stratification should be based on some type of cardiovascular risk score to estimate the 10-year risk for myocardial infarction or coronary death. In the past, the Framingham Risk Score25,26 or SCORE was recommended but future studies will likely utilize the 2013 Prevention Guidelines ASCVD Risk Estimator. The following may be used to identify men whose cardiovascular risk may exceed that estimated by a risk score calculator: a thorough history; physical examination (including measures of visceral adiposity); assessment of erectile dysfunction severity and duration; evaluation of fasting plasma glucose; resting electrocardiogram; serum creatinine (estimated glomerular filtration rate) and albumin:creatinine ratio; plasma lipid levels (total, low density lipoprotein, and HDJ cholesterol and triglyceride values) and presence or absence of the metabolic syndrome.26 The British Society of Sexual Medicine,27 Third International Consultation on Sexual Medicine,28 and Princeton III Consensus,26 all recommend that total testosterone levels be measured as a potential cause of erectile dysfunction, particularly in those for whom phosphodiesterase type 5 inhibitors have failed. Although there are no generally accepted lower limits of normal total testosterone, there is general agreement that total testosterone >350 ng/dL (12 nmol/L) does not usually require substitution and, based on data from young hypogonadal men, those with total testosterone <230 ng/dL (8 nmol/L) could be considered as candidates for testosterone treatment if they are symptomatic and appropriately monitored.29 Given the evidence that treatment of obstructive sleep apnea can improve erectile function,30,31 along with observational studies suggesting treatment of obstructive sleep apnea may improve cardiovascular outcomes,32,33 healthcare providers should also consider evaluating patients with erectile dysfunction for sleep apnea. Based on results of the above-mentioned clinical assessments, the provider may encourage lifestyle changes (e.g., diet, exercise, smoking cessation), which are likely to reduce cardiovascular risk and improve erectile function.34,35 Interventions to control specific cardiovascular risk factors (e.g., hypertension, diabetes, hyperlipidemia, obstructive sleep apnea) may also be appropriate. Men who appear to be at high risk for cardiovascular events should be referred to a cardiologist. Men who appear to be at intermediate-risk men with vasculogenic erectile dysfunction and no overt cardiovascular disease undergo further noninvasive evaluation of cardiovascular risk using exercise stress testing, carotid intima-media thickness or coronary artery calcium scoring. Recently, in a comparison of the ability of six risk markers (coronary artery calcium scoring, carotid intima-media thickness, ankle-brachial index, brachial flow–mediated dilation, high-sensitivity C-reactive protein, and family history of coronary heart disease) to improve prediction of incident coronary heart disease/cardiovascular disease in patients at intermediate risk (Framingham 10-year risk, >5%–<20%) enrolled in the Multi-Ethnic Study of Atherosclerosis, coronary artery calcium scoring provided superior improvements in risk estimation versus the other risk markers.36 Neither the most appropriate order of testing nor the prognostic superiority of one test over another has been established but both topics are the focus of ongoing research to determine the best approach to evaluate men with erectile dysfunction for subclinical vascular disease as part of the overall risk assessment. At this time, these tests should be selected based on clinical judgment, availability, and cost.


Vasculogenic erectile dysfunction should be regarded as a harbinger of silent or future cardiovascular disease. Thus, strategies that aid in the identification and characterization of erectile dysfunction may also be clinically useful for assessing and managing cardiovascular risk. In men with organic erectile dysfunction believed to be vasculogenic in etiology, cardiovascular risk should be further evaluated through assessment of traditional risk factors and noninvasive methods to detect subclinical cardiovascular disease. Cardiovascular risk stratification is now an essential component of clinical management in all men with vasculogenic erectile dysfunction.


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Keywords: Erectile Dysfunction, Cardiovascular Diseases

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