Erectile Dysfunction, Metabolic Syndrome, and Cardiovascular Risks

Facts and Controversies

Edward Sanchez; Alexander W. Pastuszak; Mohit Khera


Transl Androl Urol. 2017;6(1):28-36. 

In This Article

Screening for CVD

Given the evidence supporting a link between ED, CVD, and mortality, as well as the fact that ED may precede CV events by several years, it is recommended that men with ED be screened for CVD, with evaluation for related comorbidities where appropriate.[64] However, controversy exists as to whether the presence ED improves the prediction of CVD beyond traditional risk factors. Araujo et al. found that ED did not improve risk assessment above traditional methods such as FRS.[18] The joint 2013 American College of Cardiology/American Heart Association guideline on assessment of cardiovascular risk mentions ED as being investigated and considered as a risk predictor, but its contribution is awaiting further consideration.[65] In 2012, the Princeton III Consensus Conference aimed to focus on the predictive value of vasculogenic ED in assigning cardiovascular risk to men of all ages. The consensus recognized ED to be, in itself, an independent marker of increased risk for CVD, CAD, stroke and all-cause mortality. The panel considered all men over 30 years of age with ED to be at an increased risk for CVD, recommending thorough noninvasive and, when indicated, invasive evaluation of CVD status.[19]

While ED's role as a novel trigger for further testing may be under investigation, any sexual dysfunction evaluation is an opportunity for physicians to gather information regarding each patient's overall health profile, including any evidence of co-existing cardiac risk factors, such as hypertension, hyperlipidemia, diabetes, and smoking. Evaluation for obesity, including BMI as well as waist and hip measurements, should be considered. Validated questionnaires may also be utilized to assess the severity of sexual dysfunction [i.e., Sexual Health Inventory for Men (SHIM), IIEF] as well as assess for hypogonadism [Androgen Deficiency in the Aging Male (ADAM or qADAM)].

Initial laboratory testing includes assessment of the hypothalamic-pituitary-gonadal axis, lipid status, and sugar metabolism. The International Conference on Sexual Medicine (ICSM) recommends testing fasting blood glucose, lipid levels, and gender-specific hormones during the evaluation of sexual dysfunction in men.[66] Hemoglobin A1c is strongly associated with ED and may be considered in lieu of fasting blood glucose or in men with known diabetes.[67] Evaluation of the hypothalamic-pituitary-gonadal-axis should include determination of testosterone, free testosterone, sex hormone-binding globulin, prolactin, luteinizing hormone, and follicle-stimulating hormone levels. Recommendations for routine hormonal blood tests remain controversial, but are supported by several groups such as the Princeton III Consensus Conference, British Society for Sexual Medicine, and the International Society for Sexual Medicine.[19]

Patients should be risk stratified during their initial physician visit. The Princeton III Consensus Conference equated sexual activity to walking one mile on a flat surface in twenty minutes or climbing 2 flights of stairs in 10 seconds. Low-risk patients are those that can perform exercise of modest intensity without symptoms, and do not generally require additional cardiovascular workup prior to ED treatment. High-risk patients are those with cardiac conditions severe or unstable enough to pose a significant risk with sexual activity. Common profiles include unstable angina pectoris, uncontrolled hypertension, congestive heart failure (NYHA class IV), high risk arrhythmias (exercise induced ventricular tachycardia, implanted internal cardioverter defibrillator with frequent shocks, poorly controlled atrial fibrillation), obstructive hypertrophic cardiomyopathy, and moderate to severe valvular disease such as aortic stenosis. High-risk individuals should be referred to a cardiologist for further evaluation prior to initiation of treatment for ED and/or sexual activity. Patients considered at intermediate risk, such as those with mild or moderate angina pectoris, past MI (2–8 weeks) without intervention, congestive heart failure (NYHA class III), and non-cardiac sequelae of atherosclerotic disease (TIA, stroke, PAD), should be further evaluated with an exercise or chemical stress tests. Sexual activity is equivalent to 4 minutes of the Bruce treadmill protocol. These patients may then be categorized as low or high risk, and may proceed with treatment or further evaluation when appropriate.[19]