Intended for healthcare professionals

Rapid response to:

Head To Head

Will screening individuals at high risk of cardiovascular events deliver large benefits? Yes

BMJ 2008; 337 doi: (Published 28 August 2008) Cite this as: BMJ 2008;337:a1371

Rapid Response:

Erectile Dysfunction is the best predictor of Cardiovascular risk in men - why do we ignore it?

As a physician of 30 years experience, it disturbs me once again to
see an article on cardiovascular risk totally ignore the massive evidence
base linking erectile dysfunction (ED) with cardiovascular risk and can
tolerate this no longer. For years, I have seen patients referred with ED
after a CHD event to hear that they developed ED 2-3 years beforehand,
went to their GP but were dismissed. The facts are as follows :

Men live 7-8 years less than women. ED is the manifestation of vascular
disease in smaller arteries and gives a 2-3 year early warning of
myocardial infarction. ED carries a 50% additional risk of CHD events,a
level comparable to moderate smoking or positive first degree relative
family history. ED in type 2 diabetes is a better predictor of CHD risk
than HbA1c, hypertension, microalbuminuria or hyperlipidaemia. Over 50% of
T2Ds are hypogonadal which carries a 60% additional risk of early
cardiovascular death. Despite this evidence we don't even screen for ED or
low testosterone in type 2 diabetes or CHD patients. We prescribe drugs
for CHD which make ED worse even though there are medications as
effective, which improve ED and then make the patients pay privately
because we treat ED as a recreational or "lifestyle" issue.

Continuing to
ignore these issues on the basis that cardiologists feel uncomfortable
mentioning the word "erection" to their patients is no longer acceptable
amd probably clinically negligent. In case the authors have
missed the papers, the references are below:

Kirby M, Jackson G, Simonsen U
Endothelial dysfunction links erectile dysfunction to heart disease.
Int J Clin Pract 2005. 59 (2) 225- 229.

Kloner RA
Erectile Dysfunction and Cardiovascular Risk Factors.
Urol Clin North Am 2005: 32 (4): 397-402.

Kloner RA
Erectile Dysfunction. The new harbinger for major adverse cardiac events
in the diabetic patient.
J Am Coll Cardiol 2008: 51 (21), 2051-2052.

Laughlin GA, Barrett-Connor E, Bergstrom J
Low serum testosterone and mortality in older men
J Clin Endocrinol Metab 2008: 93 (1) 68-75.

Ma RCW, So WY, Yang XL et al.
Erectile dysfunction predicts coronary heart disease in type 2 diabetes
J Am Coll Cardiol 2008: 51 (21) 2045- 2050.

Montorsi F, Briganti A, Salonia A et al.
Erectile dysfunction prevalence, time of onset and association with risk
factors in 300 consecutive patients with acute chest pain and
angiographically documented coronary artery disease.
Eur Urol 2003: 44 (3): 360-4; discussion 364-5.

Phillips GB, Pinkernell BH, Jing TY
The association of hypotestosteronemia with coronary artery disease in
Arterioscler Thromb 1994:14 (5): 701-6.

Shabsigh R, Arver S, Channer KS et al.
The triad of erectile dysfunction, hypogonadism and the metabolic
Int J Clin Pract 2008: 62 (5) 791- 798.

Sun P, Cameron A, Seftel A, Shabsigh R et al
Erectile dysfunction - An observable marker of diabetes mellitus? A large
national epidemiological study.
J Urol 2006: 176 (3) 1081- 1085.

Thompson IM, Tangen CM, Goodman PJ et al.
Erectile dysfunction and subsequent cardiovascular disease.
JAMA 2005: 294 (23): 2996-3002.

HSC/115. 1999.
HSC/148, 1999.
HSC/177, 1999.

Araujo AB, Esche GR, Kupelian V et al.
Prevalence of symptomatic androgen deficiency in men.
J Clin Endocrinol Metab 2007: 92 (11) 4241- 4247.

Billups KL Erectile dysfunction as an early sign of cardiovascular
Int J Impot Res 2005: 17 (Suppl. 1) S19- S24.

Dusing R Sexual dysfunction in male patients with hypertension -
Influence of antihypertensive drugs
Blood Pressure 2005: 65 (6) 773- 786.

Feldman HA, Goldstein I, Hatzichristou DG et al.
Impotence and its medical and psychosocial correlates: results of the
Massachusetts Male Aging Study.
J Urol 1994: 151 (1): 54-61.

Ma R So W, Yang et al. Erectile dysfunction predicts coronary heart
disease in type 2 diabetes. J Am Coll Cardiology 2008:51: 2045-50

Gazzaruso, Solerte S B, Pujia et al. Erectile dysfunction as a
predictor of cardiovascular events and death in diabetic patients with
angiographically proven asymptomatic coronary artery disease. A protective
role for statins and PDE5 inhibitors. J Am Coll Cardio 2008:51:2040-2044

Kloner R. Erectile Dysfunction. The new harbinger of major
cardiovascular events in the diabetic patient. J Am Coll Cardiol

Laughlin GA, Barrett-Connor E, Bergstrom J
Low serum testosterone and mortality in older men
J Clin Endocrinol Metab 2008: 93 (1) 68-75.

Competing interests:
None declared

Competing interests: No competing interests

13 October 2008
Geoffrey I Hackett
Consultant in Urology (Sexual Medicine)
Good Hope Hospital, Sutton Coldfield