It is low among men who have acute coronary syndrome (ACS), mainly acute myocardial infarction with one blood vessel affected – for example, who have had a sudden heart attack without a background of furred-up arteries – but high in those with chronic coronary syndrome (CCS), mainly effort-induced angina pectoris and involving many arteries narrowed by atherosclerosis.
They have also shown in their study of nearly 300 men, that among CCS patients who had both ED and CAD, 93% reported symptoms of erectile dysfunction (ED) between one and three years before experiencing angina, with two years being the average time.
Their findings are reported on line (Wednesday 19 July) in European Heart Journal, journal of the European Society of Cardiology.
The results have prompted the researchers, from the University of Milan and the University Vita-Salute Ospedale S. Raffaele, also in Milan, to call for long-term medical surveillance in patients with ED and multiple risk factors, but with no clinical signs of coronary artery disease. They say their research has fuelled the concept of erectile dysfunction as 'sentinel of the heart'.
Their warning has been reinforced in an accompanying editorial by Dr Graham Jackson, consultant cardiologist at the Cardiothoracic Centre at Guy's and St Thomas' NHS Foundation Trust in London, UK.
"All men with ED and no cardiac symptoms need a detailed cardiac assessment, blood pressure measurement, fasting lipid profile and glucose, as well as lifestyle advice regarding weight and exercise," said Dr Jackson. "Those at cardiovascular risk ideally need stress testing and referral for risk reduction therapy, and advice with appropriate follow-up."
Lead author of the study Dr Piero Montorsi, Director 2nd department Invasive Cardiology at the Institute of Cardiology, University of Milan, explained that the study on 285 patients with CAD divided them into equal age-matched groups of 95:
"In group 1 we found just over a fifth had ED compared to nearly two-thirds in group 3 (22% versus 65%) and the control group had an ED rate similar to group 1 (24%). Group 2's ED rate was significantly different from group 1 with over half (55%) having ED. In fact, it was similar to group 3, which suggests that despite the two ACS groups having a similar clinical presentation the ED rate in ACS differs according to the extent of the coronary artery disease. So, if more than one vessel is affected in those with acute coronary syndrome, their rate of ED is actually more like that of men with chronic coronary syndrome."
Dr Montorsi said: "Age, multi-vessel coronary involvement, and CCS, were independent predictors of ED. Conversely, we were able to evaluate whether ED could predict coronary artery involvement in acute coronary syndrome and found it was associated with a four-fold risk of having multi-vessel disease as opposed to single vessel disease, independently of other conventional risk factors. In other words, patients admitted to the hospital because of acute myocardial infarction who were found to have ED (a few simple questions by the doctor are enough to make a correct diagnosis) do have a four times increased risk of diffuse coronary artery disease. This information might be useful to guide the diagnostic and therapeutic approach."
Although the study did not address whether men with ED but no other symptoms were at higher risk of future ACS or CCS as compared to those without ED, Dr Montorsi said the risk of cardiovascular events in each patient with ED but no cardiovascular symptoms should be assessed and they should be treated as necessary. "While waiting for further prospective, long-term studies, a strict medical surveillance programme should be mandatory in patients with ED, multiple risk factors and no clinical coronary artery disease."
Dr Jackson said that with an average two to three-year lead-time between ED and silent coronary artery disease becoming symptomatic there was potentially time to prevent cardiac events occurring.
"As family doctors and urologists rather than cardiologists first see these men, they have a pivotal role to play. Cardiologists need to be actively involved not only in detecting and treating ED in their own patients, but in working with urological colleagues to develop a multi-disciplinary management plan. ED is a distressing problem, which should be asked about routinely, given the successful treatment options available. As it is now widely recognised to be a warning sign for silent coronary and vascular disease, a public awareness education programme is needed to encourage men (preferably with their partners) to seek help early. Just as there is more to sex than an erect penis, there is more to ED prevention than simply restoring an erection."
 Association between erectile dysfunction and coronary artery disease. Role of coronary clinical presentation and extent of coronary vessels involvement: the COBRA trial. European Heart Journal. doli:10.1093/eurjeartj/ehl142.
 Erectile dysfunction: a market of silent coronary artery disease. European Heart Journal. doi:10.1093/eurheartj/ehl110.
A PDF of the full report is available on request from Margaret Willson.
The European Heart Journal is an official journal of the European Society of Cardiology. Please acknowledge the journal as a source in any articles.
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Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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