Urology

Can Erectile Dysfunction predict Cardiovascular Disease?

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Erectile dysfunction (ED) is a common condition in men associated with numerous comorbidities.¹However, one of the more serious links is its relationship with cardiovascular disease (CVD), which we will explore in this post.

It’s well known that patients with CVD often have ED. One study highlighted this point showing that 50% of men with proven coronary artery disease (CAD; a type of CVD) had severe ED.² However, an important question is whether ED itself can act as a clinical marker for CVD, which could potentially save many men from experiencing future cardiovascular events.

ED is consistently associated with CVD

Risk factors for CVD are similar to those for ED. For example, age, sedentary lifestyle, obesity, dyslipidemia, and metabolic syndrome are markers for both ED and CVD.¹ This has led scientists to explore this relationship in more detail and attempt to quantify the degree to which ED can predict or increase the risk of CVD.³ This will help inform healthcare professionals on what to test in men who present with ED and provide the most appropriate treatment.

In one study in 1402 men with and without ED followed for a period of 10 years, men with ED above the age of 40 were more likely to experience a cardiovascular event, such as heart attacks, sudden cardiac death, or CAD compared to those without ED. Surprisingly, men aged 40–49 who had ED were 50 times more likely to experience a CAD event than those without. In older men, the predictive value was still present, but less pronounced.⁴ These results have also been observed across other studies, including one with over 25 years’ worth of data showing men with ED have seven times the risk of a CVD event compared to those without.⁵

Digging deeper into ED and CVD

While individual studies provide helpful insight into the relationship between ED and CVD, often they report different estimates which can make interpreting this relationship difficult. This challenge can be overcome by combining the results from multiple individual studies to calculate an overall estimate, a study known as a meta-analysis.

In one such meta-analysis of 12 studies involving more than 90,000 men, ED was found to be a strong independent predictor for future cardiovascular events, with a 44% higher risk of all cardiovascular events, and a 25% higher risk of all-cause mortality.⁶ The difference in estimates compared to the previously mentioned studies can partly be explained by the differences in age brackets measured. If a study includes on average older populations, then this introduces the strong confounding variable of age, which we will discuss in more detail later on. An observation you will see regularly is that the risk of a cardiovascular event is higher in younger males with ED, as presented below.

Incidence of coronary artery disease with respect to age and ED status.4

‍Why does the relationship between ED and CVD decrease with age?

It’s important to understand why the relationship between ED and CVD diminishes with age. This is not unique to ED. In fact, with many other established risk factors the strength of the association also fades in more elderly groups. The reason for this is that age is strongly associated with many other diseases and worsening of disease markers which dramatically increases the rates of CVD in the elderly.⁷

As age increases, regardless of whether a man has ED, the proportion of men who will experience a cardiovascular event will increase too, whereas these events are typically rare in younger adults. This does not mean that ED is not an indicator for CVD in the elderly, it simply means the relationship is hidden behind numerous interacting variables that are difficult to account for in the analysis for that age group, such as higher levels of inactivity, type 2 diabetes, and other cardiovascular risk factors.

Why is ED a symptom of CVD?

To help understand why ED is a risk factor, it’s important to first understand that for erections to develop, a flow of blood must enter the penis. If this flow of blood is obstructed, then an erection will not take place.⁸ A common cause of obstructed blood flow is a process known as atherosclerosis, which is the deposition of fatty plaques called cholesterol within the arterial wall, narrowing the space available for blood to flow through.⁹ The arteries that deliver blood to the penis, called the cavernosal arteries, are smaller in diameter compared to the arteries in the heart. Therefore, cavernosal arteries tend to develop blockages from atherosclerosis long before the arteries within the heart do. It’s estimated that the obstructed cavernosal arteries causing ED precedes CAD by 3 to 5 years.^1,10

I have ED. Does this mean CVD is inevitable?

While surprising, the cardiovascular risk for men with ED is equal to the risk of lung cancer for those who smoke.¹¹ The difference here, however, is that ED itself is not a cause of CVD, it simply acts as a risk factor with a strong predictive value as they both share the same underlying cause. Understandably, if you have ED you may find its relationship with CVD extremely concerning. Though it’s important to stress that while ED can increase the chances of CVD developing, it does not make CVD inevitable. In fact, if you have ED, this may actually be a good thing in the long-run, as ED can offer an opportunity for healthcare professionals to prevent the onset of a serious cardiovascular event. It must be stressed that if you or anyone you know has concerns about ED, sexual health, or CVD, visiting a healthcare professional is strongly recommended.

Can I engage in sexual activities with ED and CVD?

If you have ED and are diagnosed with CVD, a common concern is whether engaging in any sexual activity could increase the risk of a heart attack due to acute stress. However, the majority of men with CVD can safely resume sexual activity as well as use ED therapies.¹ In fact, an expert group outlined that the cardiac risk of sexual activity in patients with diagnosed CVD is minimal in properly assessed and advised patients. They stated that sexual activity is no more stressful to the heart than many common daily activities. Avoidance of vigorous sexual activity, particularly with an unfamiliar partner, may be advisable in some men.¹²

Treating ED in patients with CVD

The use of ED therapies is safe for the majority of CVD patients. However, there are some specific ED medications that should be avoided because of the effect they can have on blood pressure. For example, a class of drugs known as PDE5 inhibitors should be avoided in patients who are on hypotensive drugs, such as nitrates in any of its forms.¹ This is because PDE5 inhibitors open (dilate) the arteries that carry blood around the body, including to the penis, with the effect that blood pressure is modestly lowered. The risk of hypotension (excessively low blood pressure) in patients on both PDE5 inhibitors and nitrates or other blood pressure lowering medications is increased.¹³ For men with CVD and ED, there are other treatment options available and it’s important to discuss these with your healthcare professional.¹

The importance of communicating sexual health issues

The British Society for Sexual Medicine has endorsed the evidence suggesting the predictive value of ED merits a re-classification for ED to be recognised as an independent risk factor for CVD. The European Society of Cardiology also recently recognised the strong evidence implying a CVD risk assessment is needed in men with ED. If we accept that ED is a predictor of CVD, then it is vital that, especially in younger patients with ED, a clinical assessment is conducted. Additionally, with the absence of other data to suggest otherwise, it would be sensible to treat ED as a risk factor for CVD for precautionary purposes.

Many CVD events are derived from male patients who also have ED but unfortunately, ED is not routinely explored in clinical practice. Healthcare professionals must enquire about ED and sexual health in general in their male patients, to ensure CVD risk is minimised and the appropriate diagnosis and treatment can be delivered.

Take home points:

There is convincing evidence to suggest ED is a strong risk factor for future cardiovascular disease
Both ED and coronary artery disease share the same underlying cause, a build up of fatty plaques within the artierial wall (this is not the only cause of ED)
Healthcare professionals should use ED as a guide to help inform diagnostic testing to ensure patients receive the correct diagnosis and correct treatment
ED itself is readily treatable, and if you are concerned about your sexual health it's strongly recommended to visit your healthcare professional

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The TRTed conversation guide to support sexual health patient care

Talking about sexual health can be challenging, but it's an important part of regular medical care. TRTed has developed a guide comprising a sample of questions and discussion points for healthcare professionals and patients to support men’s health patient care. Access here

Continue the conversation on the TRTed Community

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‍References:

Hacket G, et al. J Sex Med 2018;15:430–457.

Montorsi F, et al. Eur Urol 2003;44(3):360-365.

Ponholzer A, et al. Eur Urol 2005;48(3):512-518.

Inman BA, et al. Mayo Clin Proc 2009;84:108-113.

Chew KK, et al. J Sex Med 2010; 7:192-202.

Vlachopoulos CV, et al. Circ Cardiovasc Qual Outcomes 2013;6:99-109.

Crimmins E, et al. Adv Clin Chem 2008;46:161–216.

Panchatsharam PK, et al. Physiology, Erection. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK513278/.