It is well established that erectile dysfunction (ED) and cardiovascular disease (CVD) share common pathophysiological mechanisms and often coincide. Despite this, there is paucity of data in regards to clear clinical guidelines detailing when and how to evaluate for ED in patients with known CVD, or vice versa. This systematic and comprehensive review discuss the role of cardiologists and urologists in the characterization of risk and management of CVD in the setting of ED, as well as contrasting the current evaluation of CVD and ED from the standpoint of published consensus statements, particularly, the 2012 Princeton III Consensus and the 2013 joint American College of Cardiology/American Heart Association (ACC/AHA) guideline statement.
In this systematic review, a detailed, comprehensive literature review was performed to identify all published peer-reviewed articles in the English language describing ED and CVD across various disciplines. The search was conducted using the MEDLINE® database, the Cochrane Library® Central Search, and the Web of Science. Initial search terms were ED and CVD. Search results were screened for appropriate studies with particular emphasis placed on clinical and experimental studies as well as review articles. Articles referenced were screened to maximize review and inclusion of pertinent data. All relevant studies collected were carefully examined to extract relevant data pertaining to ED and CVD for the period between 2000 and 2015.
Historically, the associated cardiovascular risk factors, such as smoking, hypertension, and hyperlipidemia, should always be assessed in the setting of cardiovascular risk and disease. Furthermore, the 2012 Princeton III Consensus Conference expanded on the existing cardiovascular recommendations, proposing an approach to the evaluation and management of cardiovascular risk in young men with ED and no known history of diabetes, CVD, or coronary artery disease (CAD). The expert panel “considered all men with ED who are older than 30 years to be at increased CVD risk” and recommended “a thorough noninvasive and, when indicated, invasive evaluation of CVD status.” This recommendation indeed emphasizes that a question on ED should be included in all cardiovascular risk assessment and be incorporated into risk assessment guidelines. Adding to this, the assessment of testosterone levels and measures of abdominal visceral adiposity should be considered, even though their roles in development of CVD have not been firmly established
The urologist’s role is particularly critical in screening those high-risk patients (younger, moderate to severe ED, non-diabetics, no prior cardiovascular risks) and referring them to cardiology for further evaluation and assessment. The cardiologist is fundamental in determining and managing cardiovascular risk and disease. As ED is a disease of the endothelium and the vascular system and associated with an increase in cardiovascular risk, cardiologists must recognize the significance of ED and its potential sequelae, which has been highlighted in the 2012 Princeton III Consensus, recommending that a local policy for evaluation be established, which may include noninvasive evaluation including stress tests, biomarkers, and anatomical clarification.
In conclusion, several population-based studies have described a link between ED and CVD with similar pathophysiological sequelae of atherosclerosis and endothelial dysfunction. The link between ED and CVD may permit physicians, including urologists, to perform opportunistic screening and initiate secondary prophylaxis with regard to cardiovascular risk factors, particularly in young, non-diabetic men with ED.
Written by: Omer A. Raheem, MD, MSc Anat, MCh Urol, MRCS; and Tung-Chin Hsieh, MD; University of California, San Diego, Department of Urology, San Diego, CA, USA