Erectile Dysfunction: The Tip of a Vascular Risk Iceberg

How common is cardiovascular disease among men who present with erectile dysfunction?

Television ads promote a quick pharmaceutical "fix" for erectile dysfunction (ED). The afferent limb is greater recognition of the problem by health care providers and the lay public. The efferent limb is a prescription for a phosphodiesterase inhibitor. The downside of this reflex action may be a lack of insight into the clinical significance of ED.

A recent study found that sildenafil was frequently prescribed without documentation of any psychosexual disorder or ED.¹ But, although important, this is not the most troublesome issue. It has become increasingly clear that ED is merely the tip of a vascular risk iceberg.

A RED FLAG FOR VASCULAR DISEASE

A recent series of 3 articles in Archives of Internal Medicine addresses ED as a "red flag" or predictor of future vascular disease.^2-4 The papers' bibliographies recount 10 years of peer-reviewed literature that supports this new paradigm.

The first article included 221 men who had been referred for myocardial perfusion stress tests.² About 55% of them had ED. Among these men, coronary disease was more severe and the incidence of left ventricular dysfunction was higher than among those without ED.

The second study analyzed data on self-reported ED from the 2001-2002 National Health and Nutrition Examination Survey.³ As many as 1 in 5 men older than 20 years reported ED; the prevalence was highest among Hispanic men. Traditional vascular risk factors (eg, obesity, hypertension, smoking, and diabetes) were significantly associated with ED.

In the third study, 50% of a sample of nearly 4000 Canadian men aged 40 to 88 years reported ED.⁴ Cardiovascular disease, diabetes, and the metabolic syndrome were more common among the men with ED. In addition, these men had higher glucose levels and Framingham coronary risk calculations than those who did not have ED.

IMPLICATIONS FOR YOUR PRACTICE

If a patient requests treatment for ED, perform a careful history and physical examination, with particular attention to family history, smoking status, cardiac review of systems, and blood pressure. Order pertinent laboratory studies, including cholesterol, fasting glucose, and others that may be indicated over time (eg, stress testing). Treatable risk factors need to be vigorously addressed and followed for correction based on consensus recommendations (such as the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure).

If a patient does not mention ED, ask him specifically about this problem, especially if he is over age 40. It may be the first sign of future cardiovascular disease.