Can erectile dysfunction predict cardiovascular disease?

Dive into the science behind Erectile Dysfunction and Cardiovascular Disease.

June 4, 2024
Take home points:
  • There is convincing evidence that erectile dysfunction (ED) is a strong risk factor for future cardiovascular disease (CVD).
  • Both ED and coronary artery disease share the same underlying cause: a buildup of fatty plaques within the arterial wall (though this is not the only cause of ED).
  • Healthcare professionals should use ED as a guide to inform diagnostic testing, ensuring patients receive the correct diagnosis and treatment.
  • ED itself is readily treatable. Treatment guidelines should be followed to ensure patients are effectively managed.

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

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.  

Erectile dysfunction is consistently associated with cardiovascular disease

Risk factors for CVD are similar to those for ED, inlcuding older age, sedentary lifestyle, obesity, dyslipidemia, and metabolic syndrome.1  Researchers have since looked to quantify the degree to which ED can predict or increase the risk of CVD.3  

In one study of 1,402 men with and without ED followed for 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

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

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 aforementioned studies can partly be explained by the differences in study design and population, including different age brackets measured. Regardless, a consistent observation you will see is the risk of a cardiovascular events is higher in younger males with ED, as illustrated below. 

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

Why the predictive value of erectile dysfunction diminishes with age?

Understanding why the relationship between ED and CVD diminishes with age is important. This trend is not unique to ED; many other established risk factors for outcomes also show a weakening association in older age groups. The primary reason is that age itself is strongly correlated with numerous other diseases and the worsening of disease markers, which will significantly elevate CVD rates in the elderly.7

As men age, the likelihood of experiencing a cardiovascular event increases, regardless of whether they have ED. These events are typically rare in younger adults. This does not mean that ED is not an indicator of CVD in the elderly; rather, the relationship is obscured by numerous confounding variables, such as higher levels of inactivity, type 2 diabetes, and other cardiovascular risk factors, making it more difficult to account for these factors in analyses for that age group. 

Why is erectile dysfunction a sign of cardiovascular disease?

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  

If a patient has erectile dysfunction, is cardiovascular disease 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 a patient has 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 a patient has ED, this may actually be a good thing long-term, as ED can offer an opportunity for healthcare professionals to prevent the onset of a serious cardiovascular event developing later on.

Can patients engage in sexual activities with erectile dysfunction and cardiovascular disease?

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 erectile dysfunction in patients with cardiovascular disease

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 alternative treatment options available and guideline recommendations from the EAU should be followed.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.

References:
  1. Hacket G, et al. J Sex Med 2018;15:430–457.  
  1. Montorsi F, et al. Eur Urol 2003;44(3):360-365.  
  1. Ponholzer A, et al. Eur Urol 2005;48(3):512-518.
  1. Inman BA, et al. Mayo Clin Proc 2009;84:108-113.
  1. Chew KK, et al. J Sex Med 2010; 7:192-202.
  1. Vlachopoulos CV, et al. Circ Cardiovasc Qual Outcomes 2013;6:99-109.
  1. Crimmins E, et al. Adv Clin Chem 2008;46:161–216.  
  1. 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/.
  1. Berliner JA, et al. Circulation 1995;91:2388–2496.  
  1. Montorsi P, et al. Eur Heart J 2006; 27:2632-2639.
  1. Thompson IM, et al. JAMA. 2005;294(23):2996–3002.  
  1. Nehra A, et al. Mayo Clin Proc 2012;87:766-778.
  1. Kloner RA, et al. J Cardiovasc Pharmacol Ther 2018;23(5):375–386.

Something different

To access CPD learning and to make sure you don’t miss out on new content, sign-up below.

Sign up