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This Month's Question

Response by Arthur L. Burnett II, MD, Posted 09/24/07

Recent studies have shown increasing evidence for a bidirectional relationship between ED and CVD¹ and that ED may be an early indicator of the presence of latent CVD.^2-4 (Please see the June 2007 Clinical Consult). The results of a recent cross-sectional analysis of data from the National Health and Nutritional Survey (NHANES) showed that nearly 90% of men with ED have at least 1 major CVD risk factor, such as hypertension (HTN), dyslipidemia, smoking, or diabetes¹; thus, reinforcing the notion that vascular disease is considered the most common pathologic risk factor for organic ED.^3,5,6

Expanding upon the findings of the Massachusetts Male Aging Study (MMAS), my colleagues and I analyzed data from the NHANES study (N=2126) and investigated the prevalence of CVD risk factors among patients with ED. We found that the prevalence of ED among men between the ages of 40 and 70 is 20.1%¹ with 14.8% of men aged 40 to 59 years, 43.8% of men aged 60 to 69 years, and 70.2% of men 70 years and older experiencing ED, defined in this study as the inability (sometimes or never) to attain an erection adequate for sexual intercourse.¹ In the MMAS study (n=513), the overall prevalence of ED was shown to be approximately 52% for patients between the ages of 40 and 70 years²; ED was defined in this study as the inability (usually able, sometimes, or never) to attain an erection adequate for sexual intercourse.¹ Both studies demonstrated a higher prevalence of CVD risk factors (eg, HTN, obesity, smoking, dyslipidemia, prior history of CVD, and diabetes) in patients with ED than in patients without ED.^1,7

In another analysis of NHANES data, it was demonstrated that ED may develop in men with CVD risk factors as a result of prescribed medication. Hypertensive men taking certain antihypertensive medications such as spironolactone, thiazide diuretics, beta blockers, methyldopa, and clonidine were 3-fold more likely to develop ED than normotensive men and 2.4-fold more likely to develop ED than hypertensive men who did not take medication.⁸ The development of ED as a result of CVD medication may play a disruptive role in treatment adherence. In a retrospective observational study analyzing treatment adherence determined by medication possession ratios, McLaughlin et al suggested that treatment of ED with PDE5 inhibitors increased adherence to concomitant medication in patients who became nonadherent due to medication-induced ED. Of patients taking medication for hypertension who were previously nonadherent, approximately 21% became adherent after receiving a prescription of a PDE5 inhibitor.⁹

In addition to sharing common risk factors with CVD, ED may be an early marker for occult CVD or disease progression.^2,10,11 Therefore, screening is warranted and is considered highly appropriate to evaluate ED risk when a patient presents with CVD symptoms. A targeted medical, sexual, and psychosocial history, in conjunction with a physical examination and laboratory tests, may provide a strong basis for a treatment plan for men with CVD and ED,¹² as their risk factors are often modifiable.⁷

References

1. Selvin E, Burnett AL, Platz EA. Prevalence and risk factors for erectile dysfunction in the US. Am J Med. 2007;120:151-157.

2. Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, McKinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol. 1994;151:54-61.

3. Jackson G, Rosen RC, Kloner RA, Kostis JM. The second Princeton Consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. J Sex Med. 2006;3:28-36.

4. Thompson IM, Tangen CM, Goodman PJ, Probstfield JL, Moinpour CM, Coltman CA. Erectile dysfunction and subsequent cardiovascular disease. 2005;294:2996-3002.

5. Solomon H, Man J, Wierzbicki AS, O'Brien T, Jackson G. Erectile dysfunction: cardiovascular risk and the role of the cardiologist. Int J Clin Pract. 2003;57:96-99.

6. Sullivan ME, Keoghane SR, Miller MAW. Vascular risk factors and erectile dysfunction. BJU Int. 2001;87:838-845.

7. Feldman HA, Johannes CB, Derby CA, et al. Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts Male Aging Study. Prev Med. 2000;30:328-338.

8. Francis ME. The contribution of common medical conditions and drug exposures to erectile dysfunction in adult males. J Urol. 2007;178:591-596.

9. McLaughlin T, Harnett J, Burhani S, Scott B. Evaluation of erectile dysfunction therapy in patients previously nonadherent to long-term medications: a retrospective analysis of prescription claims. Am J Ther. 2005;12:605-611.

10. DeBusk R, Drory Y, Goldstein I, et al. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel. Am J Cardiol. 2000;86:175-181.

11. Kirby M, Jackson G, Betteridge J, Friedli K. Is erectile dysfunction a marker for cardiovascular disease? Int J Clin Pract. 2001;55:614-618.

12. Barrett-Connor E. Cardiovascular risk stratification and cardiovascular risk factors associated with erectile dysfunction: Assessing cardiovascular risk in men with erectile dysfunction. Clin Cardiol. 2004;27:18-I-13.