Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus

Abstract

Summary A significant proportion of men with erectile dysfunction (ED) exhibit early signs of coronary artery disease (CAD), and this group may develop more severe CAD than men without ED (Level 1, Grade A). The time interval among the onset of ED symptoms and the occurrence of CAD symptoms and cardiovascular events is estimated at 2–3 years and 3–5 years respectively; this interval allows for risk factor reduction (Level 2, Grade B). ED is associated with increased all‐cause mortality primarily due to increased cardiovascular mortality (Level 1, Grade A). All men with ED should undergo a thorough medical assessment, including testosterone, fasting lipids, fasting glucose and blood pressure measurement. Following assessment, patients should be stratified according to the risk of future cardiovascular events. Those at high risk of cardiovascular disease should be evaluated by stress testing with selective use of computed tomography (CT) or coronary angiography (Level 1, Grade A). Improvement in cardiovascular risk factors such as weight loss and increased physical activity has been reported to improve erectile function (Level 1, Grade A). In men with ED, hypertension, diabetes and hyperlipidaemia should be treated aggressively, bearing in mind the potential side effects (Level 1, Grade A). Management of ED is secondary to stabilising cardiovascular function, and controlling cardiovascular symptoms and exercise tolerance should be established prior to initiation of ED therapy (Level 1, Grade A). Clinical evidence supports the use of phosphodiesterase 5 (PDE5) inhibitors as first‐line therapy in men with CAD and comorbid ED and those with diabetes and ED (Level 1, Grade A). Total testosterone and selectively free testosterone levels should be measured in all men with ED in accordance with contemporary guidelines and particularly in those who fail to respond to PDE5 inhibitors or have a chronic illness associated with low testosterone (Level 1, Grade A). Testosterone replacement therapy may lead to symptomatic improvement (improved wellbeing) and enhance the effectiveness of PDE5 inhibitors (Level 1, Grade A). Review of cardiovascular status and response to ED therapy should be performed at regular intervals (Level 1, Grade A).

The Princeton III Consensus Recommendations for the Management of Erectile Dysfunction and Cardiovascular Disease

“…6 • ED not only shares risk factors with CVD 7,8 but also is, in itself, an independent marker of increased risk for CVD (ACCF/AHA class Ia). [9][10][11][12][13][14][15] • ED is a marker of significantly increased risk of CVD, coronary artery disease (CAD), stroke, and all-cause mortality.…”

“…38,39 The consensus panel recommends that testosterone levels be measured in all men with a diagnosis of organic ED, especially in those for whom PDE5 inhibitor therapy failed. 6 This recommendation may be controversial, and it differs from the guideline published by the American College of Physicians, 40 which does not recommend for or against routine hormonal blood tests or treatment in patients with ED. However, the British Society for Sexual Medicine and the International Society for Sexual Medicine advocate testosterone measurements (Ն2) in all men with ED.…”

“…Completing 4 minutes of the standard Bruce treadmill protocol (5-6 Mets) without symptoms, arrhythmias, or a fall in systolic BP identifies the safety of sexual activity. 1,2,6 Based on stress test results, they will be reassigned to low-or high-risk groups as recommended after the first and second Princeton Consensus Conferences. Chemical stress tests (eg, dipyridamole or adenosine with nuclear imaging) are appropriate if the patient cannot complete a standard exercise test (eg, owing to a disabling condition such as arthritis).…”

Can Erectile Dysfunction in Young Patients Serve as a Surrogate Marker for Coronary Artery Disease?

“…Despite this, there are limited data on the prevalence of ED and its association with angiographically documented CAD in these patient populations. Patients were divided into groups based on IIEF-5 scores as no ED (22)(23)(24)(25), mild (17)(18)(19)(20)(21), mild to moderate (12)(13)(14)(15)(16), moderate (8)(9)(10)(11), and severe (<7) ED [13]. Patients with abnormal parameters were assessed by cardiologists by echocardiography, stress test and if necessary coronary angiography (Non-Invasive or Invasive).…”

An advisory service for men's sexual concerns

“…In the case of atherosclerosis, the early recognition of these clinical conditions is important to allow treatment and so reduce cardiovascular risk. 3 Vigilance with regards to testosterone levels in cases of sexual dysfunction has been shown to be important now that it has been realised that a fall in testosterone and development of erectile dysfunction …”