Elsevier

European Urology

Volume 65, Issue 5, May 2014, Pages 968-978
European Urology

Platinum Priority – Collaborative Review – Andrology
Editorial by Hillary A. Keenan on pp. 979–980 of this issue
A Systematic Review of the Association Between Erectile Dysfunction and Cardiovascular Disease

https://doi.org/10.1016/j.eururo.2013.08.023Get rights and content

Abstract

Context

Erectile dysfunction (ED) is considered a vascular impairment that shares many risk factors with cardiovascular disease (CVD). A correlation between ED and CVD has been hypothesized, and ED has been proposed as an early marker of symptomatic CVD.

Objective

To analyze the relationship between ED and CVD, evaluating the pathophysiologic links between these conditions, and to identify which patients would benefit from cardiologic assessment when presenting with ED.

Evidence acquisition

A systematic literature review searching Medline, Embase, and Web of Science databases was performed. The search strategy included the terms erectile dysfunction, cardiovascular disease, coronary artery disease, risk factors, pathophysiology, atherosclerosis, low androgen levels, inflammation, screening, and phosphodiesterase type 5 inhibitors alone or in combination. We limited our search to studies published between January 2005 and May 2013.

Evidence synthesis

Several studies reported an association between ED and CVD. The link between these conditions might reside in the interaction between androgens, chronic inflammation, and cardiovascular risk factors that determines endothelial dysfunction and atherosclerosis, resulting in disorders of penile and coronary circulation. Because penile artery size is smaller compared with coronary arteries, the same level of endothelial dysfunction causes a more significant reduction of blood flow in erectile tissues compared with that in coronary circulation. Thus ED could be an indicator of systemic endothelial dysfunction. From a clinical standpoint, because ED may precede CVD, it can be used as an early marker to identify men at higher risk of CVD events. ED patients at high risk of CVD should undergo detailed cardiologic assessment and receive intensive treatment of risk factors.

Conclusions

ED and CVD should be regarded as two different manifestations of the same systemic disorder. ED usually precedes CVD onset, and it might be considered an early marker of symptomatic CVD.

Introduction

Erectile dysfunction (ED) is defined as the recurrent or consistent inability to obtain and/or maintain a penile erection sufficient for satisfactory sexual performance [1]. The incidence of ED increases with age, reaching 20–40% in men 60–69 yr of age and 50–100% in men in their 70s and 80s, depending on the differing definitions of ED in various studies [2]. Beyond the aging process, other cardiovascular (CV) risk factors such as hypertension, diabetes, smoking, obesity, and dyslipidemia have been shown to be significantly associated with ED [3], [4]. For this reason, a correlation between ED and cardiovascular disease (CVD) has been hypothesized, and ED has been proposed as an early manifestation of a larger subclinical systemic disorder that might subsequently result in CVD [5], [6].

This review analyzes the relationship between ED and CVD by addressing the pathophysiologic links between these two conditions and by examining the role of ED as an early sign of symptomatic CVD. We also focus on the clinically relevant aspects of this association, in order to identify which patients would benefit from a detailed cardiologic assessment.

Section snippets

Evidence acquisition

A systematic literature review was performed in May 2013 using the Medline, Embase, and Web of Science databases. The search strategy included the terms erectile dysfunction, coronary artery disease, cardiovascular disease, risk factors, pathophysiology, artery-size hypothesis, atherosclerosis, low androgen levels, inflammation, screening, and phosphodiesterase type 5 inhibitors, alone or in combination. We limited our search to prospective trials and major preclinical and retrospective studies

Clinical evidence of association between erectile dysfunction and cardiovascular disease: common risk factors

ED is commonly considered a vascular disease, and it is well known to share many risk factors with CVD such as aging, hypertension, smoking, diabetes, obesity, and metabolic syndrome [3], [4]. In this context, a large prospective trial evaluating the impact of CV risk factors on erectile function during a 25-yr follow-up clearly showed that age, body mass index (BMI), cholesterol, and triglycerides were significantly associated with ED [4]. Additional CV risk factors such as smoking, BMI,

Conclusions

ED and CVD should be considered two different manifestations of the same systemic disorder. The link between these conditions resides in the interaction between CV risk factors, androgens, and chronic inflammation, which leads to atherosclerosis and flow-limiting stenosis. Macroscopically invisible alterations, such as endothelial dysfunction and autonomic hyperactivity, might in part explain the complex relationship between ED and CVD. ED usually precedes CVD, and its diagnosis offers a window

References (68)

  • C. Gazzaruso et al.

    Erectile dysfunction as a predictor of cardiovascular events and death in diabetic patients with angiographically proven asymptomatic coronary artery disease: a potential protective role for statins and 5-phosphodiesterase inhibitors

    J Am Coll Cardiol

    (2008)
  • R.C. Ma et al.

    Erectile dysfunction predicts coronary heart disease in type 2 diabetes

    J Am Coll Cardiol

    (2008)
  • B.A. Inman et al.

    A population-based, longitudinal study of erectile dysfunction and future coronary artery disease

    Mayo Clin Proc

    (2009)
  • A.B. Araujo et al.

    Erectile dysfunction and mortality

    J Sex Med

    (2009)
  • G.D. Batty et al.

    Erectile dysfunction and later cardiovascular disease in men with type 2 diabetes: prospective cohort study based on the ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation) trial

    J Am Coll Cardiol

    (2010)
  • J.M. Hotaling et al.

    Erectile dysfunction is not independently associated with cardiovascular death: data from the Vitamins and Lifestyle (VITAL) study

    J Sex Med

    (2012)
  • J.Y. Dong et al.

    Erectile dysfunction and risk of cardiovascular disease: meta-analysis of prospective cohort studies

    J Am Coll Cardiol

    (2011)
  • H. Solomon et al.

    Relation of erectile dysfunction to angiographic coronary artery disease

    Am J Cardiol

    (2003)
  • C. Gratzke et al.

    Anatomy, physiology, and pathophysiology of erectile dysfunction

    J Sex Med

    (2010)
  • G. Jackson et al.

    Cardiovascular aspects of sexual medicine

    J Sex Med

    (2010)
  • S.T. Chang et al.

    Coronary phenotypes in patients with erectile dysfunction and silent ischemic heart disease: a pilot study

    J Sex Med

    (2010)
  • M. Gacci et al.

    Critical analysis of the relationship between sexual dysfunctions and lower urinary tract symptoms due to benign prostatic hyperplasia

    Eur Urol

    (2011)
  • E. Chiurlia et al.

    Subclinical coronary artery atherosclerosis in patients with erectile dysfunction

    J Am Coll Cardiol

    (2005)
  • M. Bocchio et al.

    Endothelial cell activation in men with erectile dysfunction without cardiovascular risk factors and overt vascular damage

    J Urol

    (2004)
  • C. Vlachopoulos et al.

    Inflammation, metabolic syndrome, erectile dysfunction, and coronary artery disease: common links

    Eur Urol

    (2007)
  • V. Mirone et al.

    Androgens and morphologic remodeling at penile and cardiovascular levels: a common piece in complicated puzzles?

    Eur Urol

    (2009)
  • A.M. Traish et al.

    Testosterone and erectile function: from basic research to a new clinical paradigm for managing men with androgen insufficiency and erectile dysfunction

    Eur Urol

    (2007)
  • J. Mulhall et al.

    Vasculogenic erectile dysfunction is a predictor of abnormal stress echocardiography

    J Sex Med

    (2009)
  • K. Garcia-Malpartida et al.

    Relationship between erectile dysfunction and silent myocardial ischemia in type 2 diabetic patients with no known macrovascular complications

    J Sex Med

    (2011)
  • A. Nehra et al.

    The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease

    Mayo Clin Proc

    (2012)
  • B.G. Schwartz et al.

    Cardiac uses of phosphodiesterase-5 inhibitors

    J Am Coll Cardiol

    (2012)
  • Impotence. NIH Consensus Development Panel on Impotence

    JAMA

    (1993)
  • P. Montorsi et al.

    The artery size hypothesis: a macrovascular link between erectile dysfunction and coronary artery disease

    Am J Cardiol

    (2005)
  • G. Gandaglia et al.

    Erectile dysfunction as a cardiovascular risk factor in patients with diabetes

    Endocrine

    (2013)
  • Cited by (0)

    View full text