Erectile Dysfunction Is an Independent Predictor of Cardiovascular Events

Erectile dysfunction (ED) was an independent predictor of cardiovascular disease in a large, multiethnic, community-based cohort of men, even after controlling for other factors that have long been considered to complicate the connection between erectile problems and heart disease, new research shows.

According to S. M. Iftekhar Uddin, MBBS (Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD), and colleagues, their study “provides some of the strongest evidence to date for the independent predictive value of ED in a modern, multiethnic, well-phenotyped cohort.”

The findings underscore the need for better, more direct communication between urologists, primary care physicians, and cardiologists, senior author Michael Blaha, MD (Johns Hopkins Ciccarone Center for the Prevention of Heart Disease), told TCTMD, adding that a patient who sees his doctor about erectile dysfunction and isn’t also worked up for cardiovascular disease represents a missed opportunity. “Patients may feel shortness of breath and things like that, but [erectile dysfunction] is the symptom that's most likely to get a man to go into the [doctor's] office,” Blaha said.

When that happens, he continued, many physicians will simply order a testosterone panel, ask about mental health, or prescribe ED drugs. “It's important for people who treat ED . . . and cardiovascular specialists to closely communicate about these patients, and for many patients with ED to get a cardiovascular assessment,” Blaha said. “I've run into plenty of patients who hadn't even thought about erectile dysfunction as a vascular problem—they hadn't even made the connection that, of course, blood flow is through the whole body. So, making those connections is important.”

I've run into plenty of patients who hadn't even thought about erectile dysfunction as a vascular problem—they hadn't even made the connection that, of course, blood flow is through the whole body. Michael Blaha

Uddin, Blaha, and colleagues published their analysis as a research letter this week in Circulation.

Cumulative Dysfunction

The analysis included 1,757 male patients participating in the Multi-Ethnic Study of Atherosclerosis (MESA) who were free of cardiovascular disease before their first clinic visit and who had also answered survey questions on erectile dysfunction symptoms. A full 45.8% of the participants, mean age of 69, answered “sometimes” or “never” to the Massachusetts Male Aging Study single question pertaining to the ability to get and sustain an erection.

Over a mean follow-up of 3.8 years, 2.3% of the cohort experienced a “hard coronary heart disease [CHD] event” (myocardial infarction, resuscitated cardiac arrest, or CHD death) and 4.3% of participants experienced a hard CVD event (CHD event or fatal/nonfatal stroke).

In keeping with prior studies, coronary and cardiovascular disease events were more than two times more common among men who also reported erectile dysfunction. In analyses that adjusted for conventional risk factors, as well as beta-blocker use and depression—both commonly associated with ED—erectile dysfunction remained a significant predictor of CVD events (HR 1.9; 95% CI 1.1-3.4). Hard CHD events also trended higher, but the difference did not reach statistical significance after adjustment.

“To our knowledge, this is the first study of ED and subsequent CVD that adjusted for depression and beta-blocker use,” the authors conclude. “Our results suggest that these two factors may partially mediate the relationship between prior CVD and subsequent ED, but do not attenuate the prospective association of ED and incident CVD.”

Speaking with TCTMD, Blaha clarified that calling erectile dysfunction an “independent risk factor” does not imply causation. Rather, it singles out that erectile dysfunction is “an end-organ manifestation of vascular disease” that cannot be completely predicted through traditional risk factors. That’s because assessment of risk factors—things like blood pressure, lipids, physical fitness, and particulate exposure—cannot be “perfectly” measured. As such, he continued, “the presence of ED tells us something about the cumulative dysfunction of the cardiovascular system that we couldn’t have gathered just from the simple measurement of risk factors alone.”

Blaha also acknowledged that the study is not the first to identify ED as an independent predictor of risk, but said it is the first to confirm this relationship in a large, contemporary, multiethnic cohort. Current US guidelines for the assessment of cardiovascular disease risk make no mention of erectile dysfunction as a risk predictor, he noted. On the basis of this study and others, he said, “I would argue that in future guidelines there should be a discussion of ED as an independent risk factor, [and] that should heighten your attention towards assessing CV risk in these patients.”