Erectile dysfunction may predict coronary artery disease: relationship between coronary artery calcium scoring and erectile dysfunction severity

Carotid artery intima media thickness can predict the response to phosphodiesterase 5 inhibitors in patients with moderate erectile dysfunction

Background

Increased carotid artery intima-media thickness (CIMT) has been shown to be associated with erectile dysfunction (ED), but studies evaluating the efficacy of CIMT in predicting drug response are lacking in the literature.

Aim

We aimed to evaluate the efficacy of CIMT in predicting the response to phosphodiesterase-5 inhibitors (PDE5-I).

Methods

A total of 274 subjects were divided into two groups: ED patients (n = 150) and controls (n = 124). The patients in the ED group were further divided into the subgroups of severe, moderate, mild-moderate, and mild ED. Blood tests, carotid ultrasonography, and the International Index of Erectile Function-5 (IIEF-5) diagnostic tool were applied to all subjects. Tadalafil was administered to each patient. The patients were re-evaluated using the IIEF-5 questionnaire after 2 months of treatment. According to their response to medication, the patients were evaluated as responders or nonresponders.

Outcomes

Increased CIMT was significantly associated with the failure of PDE5-I therapy, especially in patients with moderate/mild-moderate ED.

Results

Fasting blood glucose, body mass index, and CIMT were significantly higher in the ED group compared to the control group (P = .021, P = .006, and P < .001, respectively). The IIEF-5 score was significantly lower in the ED group (P < .001). CIMT was significantly correlated with the IIEF-5 score. When the total patient group was evaluated, the CIMT value of the responders was significantly lower than that of the nonresponders (P = .001). CIMT was significantly higher among the nonresponders with moderate/mild-moderate ED compared to the responders (P = .004 and .008, respectively), while there was no significant difference in CIMT between the responders and nonresponders with severe or mild ED. A receiver operating characteristic (ROC) analysis of CIMT was performed for discrimination between nonresponders and responders with moderate/mild-moderate ED. The area under the ROC curve was 0.801 (0.682-0.921) (P = .001), and the cutoff value was determined to be 0.825 mm, at which CIMT predicted the response to treatment with 65% sensitivity and 89% specificity.

Clinical Implications

Using a validated CIMT cutoff value can help the physician inform the patient about the possibility of drug failure and avoid attempting second-line therapy too soon.

Strengths and Limitations

There are three main limitations to our study. First, the number of participants was low. Second, ultrasound is a relatively subjective method, and third, all measurements were made by the same radiologist.

Conclusion

CIMT can be used as a predictor of response to PDE5-I therapies in patients with moderate/mild-moderate ED.

Endothelial Dysfunction, Erectile Deficit and Cardiovascular Disease: An Overview of the Pathogenetic Links

Erectile dysfunction (ED) is a condition with multifactorial pathogenesis, quite common among men, especially those above 60 years old. A vascular etiology is the most common cause. The interaction between chronic inflammation, androgens, and cardiovascular risk factors determines macroscopically invisible alterations such as endothelial dysfunction and subsequent atherosclerosis and flow-limiting stenosis that affects both penile and coronary arteries. Thus, ED and cardiovascular disease (CVD) should be considered two different manifestations of the same systemic disorder, with a shared aetiological factor being endothelial dysfunction. Moreover, the penile arteries have a smaller size compared with coronary arteries; thus, for the same level of arteriopathy, a more significant blood flow reduction will occur in erectile tissue compared with coronary circulation. As a result, ED often precedes CVD by 2–5 years, and its diagnosis offers a time window for cardiovascular risk mitigation. Growing evidence suggests, in fact, that patients presenting with ED should be investigated for CVD even if they have no symptoms. Early detection could facilitate prompt intervention and a reduction in long-term complications. In this review, we provide an overview of the pathogenetic mechanisms behind arteriogenic ED and CVD, focusing on the role of endothelial dysfunction as the common denominator of the two disorders. Developed algorithms that may help identify those patients complaining of ED who should undergo detailed cardiologic assessment and receive intensive treatment for risk factors are also analyzed.

Erectile dysfunction and coronary artery calcification in incident dialysis patients

PURPOSE

Erectile dysfunction, which has been associated with mortality in the general population, is common in individuals on hemodialysis. Our aim was to determine the relationship between erectile dysfunction, coronary artery calcification and mortality in incident hemodialysis patients.

MATERIALS AND METHODS

A prospective cohort of incident adult dialysis patients with no history of coronary artery disease underwent coronary artery calcification measurement by ECG-triggered multi-slice computed tomography (MSCT) scan at baseline and at least 12 months later. Erectile dysfunction was determined using the 15-item validated International Index of Erectile Function (IIEF-15) questionnaire.

RESULTS

Erectile dysfunction was prevalent in 83% of patients, with 43% classified as severe erectile dysfunction, 22.4% as moderate erectile dysfunction, and 17.2% as mild erectile dysfunction. The median (IQR) coronary artery calcification score was 43.4 (0.25-353.8) for those with erectile dysfunction and 0 (0-0) for those without erectile dysfunction (p = 0.007). More than half (55.6%) of the patients with erectile dysfunction experienced progression of coronary artery calcification compared to 14.3% of patients without erectile dysfunction (p = 0.05). Mortality was 21% during an average follow-up of 5.2 (1.3) years. Twenty-three percent of patients with erectile dysfunction died compared to 10% of people without erectile dysfunction (p = 0.4). Erectile dysfunction was not significantly associated with mortality [HR 1.2 (1.3), p = 0.87].

CONCLUSIONS

Erectile dysfunction is common in individuals who start dialysis. It is significantly associated with an increased coronary artery calcification score, however, it is not associated with increased mortality in incident dialysis patients with no history of coronary artery disease.

Pharmacology and perspectives in erectile dysfunction in man

Penile erection is a perfect example of microcirculation modulated by psychological factors and hormonal status. It is the result of a complex neurovascular process that involves the integrative synchronized action of vascular endothelium; smooth muscle; and psychological, neuronal, and hormonal systems. Therefore, the fine coordination of these events is essential to maintain penile flaccidity or allow erection; an alteration of these events leads to erectile dysfunction (ED). ED is defined as the consistent or recurrent inability of a man to attain and/or maintain a penile erection sufficient for sexual activity. A great boost to this research field was given by commercialization of phosphodiesterase-5 (PDE5) inhibitors. Indeed, following the discovery of sildenafil, research on the mechanisms underlying penile erection has had an enormous boost, and many preclinical and clinical papers have been published in the last 10 years. This review is structured to provide an overview of the mediators and peripheral mechanism(s) involved in penile function in men, the drugs used in therapy, and the future prospective in the management of ED. Indeed, 30% of patients affected by ED are classified as "nonresponders," and there is still an unmet need for therapeutic alternatives. A flowchart suggesting the guidelines for ED evaluation and the ED pharmacological treatment is also provided.

Association Between Erectile Dysfunction and Carotid Subclinical Atherosclerosis in HIV-Infected Patients

BACKGROUND

Erectile dysfunction (ED) is frequent in HIV-infected patients, and it can be associated with atherosclerosis and cardiovascular events. So, the objective was to evaluate whether the presence of moderate-severe ED was a marker of subclinical atherosclerosis (SCA) in HIV-infected patients.

METHODS

A cross-sectional study was conducted in a cohort of HIV-infected patients. The presence of ED was assessed using the International Index of Erectile Function (IIEF-5) questionnaire. The presence of SCA was determined by calculating the mean carotid intima-media thickness with Doppler ultrasound. A logistic regression analysis was performed to check the variables associated with SCA.

RESULTS

One hundred thirty-nine men of 45 (10) years of age were included, of which 130 (94.9%) received antiretroviral therapy. In 30 (22%) patients, the Framingham score was higher than 10%. In 36 (25.9%) patients, ED was detected in a moderate-severe degree and in 53 (38.1%), SCA was detected. In the multivariate analysis, variables independently associated with the presence of SCA were as follows: older age [odds ratio (OR) = 1.22, confidence interval (CI) 95%: 1.1 to 1.35, P < 0.001] and moderate-severe ED (OR = 4.68, CI 95%: 1.18 to 18.5; P = 0.028). Variables associated with moderate-severe ED were as follows: age (OR = 1.107, CI 95%: 1.041 to 1.17, P < 0.001) and having antibodies for hepatitis C virus (OR = 5.12, CI 95%: 1.54 to 17.03, P < 0.001).

CONCLUSIONS

HIV-Infected patients often have moderate-severe ED, especially the elderly and coinfected patients with hepatitis C virus. ED can be an early clinical manifestation of incipient atherosclerosis, so its presence should involve a deep control of cardiovascular risk factors and using a regimen with a better atherogenic profile.

The Intersection of Medicine and Urology: An Emerging Paradigm of Sexual Function, Cardiometabolic Risk, Bone Health, and Men's Health Centers

Men's mental health and how they think about their health are critical to the future of men's health. Poor health choice patterns are established under age 50, when men are twice as likely to die than women. As the future of medicine focuses on quality and value, a better understanding of the social determinants of men's health will identify areas for improvement. The presentation of a man to a clinician's office with a sexual health complaint presents an opportunity for more complete evaluation. The future of men's health will be well served by integrated men's health centers that focus on the entire man.

The relationship of erectile dysfunction and subclinical cardiovascular disease: A systematic review and meta-analysis

Erectile dysfunction (ED) is associated with cardiovascular disease (CVD) and CVD mortality. However, the relationship between ED and subclinical CVD is less clear. We synthesized the available data on the association of ED and measures of subclinical CVD. We searched multiple databases for published literature on studies examining the association of ED and measures of subclinical CVD across four domains: endothelial dysfunction measured by flow-mediated dilation (FMD), carotid intima–media thickness (cIMT), coronary artery calcification (CAC), and other measures of vascular function such as the ankle–brachial index, toe–brachial index, and pulse wave velocity. We conducted random effects meta-analysis and meta-regression on studies that examined an ED relationship with FMD (15 studies; 2025 participants) and cIMT (12 studies; 1264 participants). ED was associated with a 2.64 percentage-point reduction in FMD compared to those without ED (95% CI: –3.12, −2.15). Persons with ED also had a 0.09-mm (95% CI: 0.06, 0.12) higher cIMT than those without ED. In subgroup meta-analyses, the mean age of the study population, study quality, ED assessment questionnaire (IIEF-5 or IIEF-15), or the publication date did not significantly affect the relationship between ED and cIMT or between ED and FMD. The results for the association of ED and CAC were inconclusive. In conclusion, this study confirms an association between ED and subclinical CVD and may shed additional light on the shared mechanisms between ED and CVD, underscoring the importance of aggressive CVD risk assessment and management in persons with ED.

Vascular Erectile Dysfunction and Subclinical Cardiovascular Disease

PURPOSE OF REVIEW

We review the recent literature on the hypothesized temporal relationship between subclinical cardiovascular disease (CVD), vascular erectile dysfunction (ED), and clinical CVD. In addition, we combine emerging research with expert consensus guidelines such as The Princeton Consensus III to provide a preventive cardiologist's perspective toward an ideal approach to evaluating and managing CVD and ED risk in patients.

RECENT FINDINGS

Development of ED was found to occur during the progression from subclinical CVD to clinical CVD. A strong association was observed between subclinical CVD as assessed by coronary artery calcium (CAC) and carotid plaque and subsequent ED, providing evidence for the role of subclinical CVD in predicting ED. ED is also identified as a substantial independent risk factor for overt clinical CVD, and ED symptoms may precede CVD symptoms by 2-3 years.

SUMMARY

Given the body of evidence on the relationship between subclinical CVD, ED, and clinical CVD we recommend that all men with vascular ED should undergo cardiovascular risk assessment. We further recommend using CAC scores for advanced risk assessment in patients at low-intermediate to intermediate risk (5-20% CVD risk), with risk driving subsequent lifestyle and pharmacologic treatment decisions.

Penile Erection Induced by Scoparone from Artemisia capillaris through the Nitric Oxide-Cyclic Guanosine Monophosphate Signaling Pathway

Purpose

The objective of this study was to evaluate the relaxant effect of scoparone from Artemisia capillaris on rabbit penile corpus cavernosum smooth muscle (PCCSM) and to elucidate the mechanism of action of scoparone for the treatment of erectile dysfunction (ED).

Materials and Methods

PCCSM that had been precontracted with phenylephrine was treated with 3 Artemisia herbs (A. princeps, A. capillaris, and A. iwayomogi) and 3 fractions (n-hexane, ethyl acetate, and n-butanol) with different concentrations (0.1, 0.5, 1.0, and 2.0 mg/mL). Four components (esculetin, scopoletin, capillarisin, and scoparone) isolated from A. capillaris were also evaluated. The PCCSM was preincubated with Nω-nitro-L-arginine methyl ester hydrochloride (L-NAME) and 1H-[1,2,4] oxadiazolo [4,3-a]quinoxalin-1-one (ODQ). Cyclic nucleotides in the perfusate were measured by a radioimmunoassay. The interactions of scoparone with udenafil and rolipram were also evaluated.

Results

A. capillaris extract relaxed PCCSM in a concentration-dependent manner. Scoparone had the highest relaxant effect on PCCSM among the 4 components (esculetin, scopoletin, capillarisin, and scoparone) isolated from the ethyl acetate fraction. The application of scoparone on PCCSM pretreated with L-NAME and ODQ led to significantly less relaxation. Scoparone also increased the cyclic guanosine monophosphate (cGMP) levels in the perfusate in a concentration-dependent manner. Furthermore, scoparone enhanced udenafil- and rolipram-induced relaxation of the PCCSM.

Conclusions

Scoparone relaxed the PCCSM mainly by activating the nitric oxide-cGMP signaling pathway, and it may be a new promising treatment for ED patients who do not completely respond to udenafil.

Recent advances in the treatment of erectile dysfunction

Erectile dysfunction (ED) is one of the most common conditions affecting middle-aged and older men. Nearly every primary care physician, internist and geriatrician will be called upon to manage this condition or to make referrals to urologists, endocrinologists and cardiologists who will assist in the treatment of ED. This article will briefly discuss the diagnosis and management of ED. In addition, emerging concepts in ED management will be discussed, such as the use of testosterone to treat ED, the role of the endothelium in men with ED and treating the partner of the man with ED. Finally, future potential therapies for ED will be discussed.

Recent advances in magnetoliposome for heart drug delivery

Magnetic nanoparticles (NPs) also have been subject of interest to the therapeutic and imaging field because of their unique magnetic properties. Magnetoliposomes (MLs) are made up of a combination of liposomes and magnetic NPs, and they have been proven to be a potential biomaterial to fields like magnetic-targeted drug delivery, MRI, etc. The efficiency of a drug delivery system to the heart determines the treatment strategy for most of the heart diseases. In this review article, we summarize the recent development and updates in the application of MLs as a drug delivery system for heart/cardiac diseases.

Relation Between Erectile Dysfunction and Silent Myocardial Ischemia in Diabetic Patients: A Multidetector Computed Tomographic Coronary Angiographic Study

INTRODUCTION

Erectile dysfunction (ED) can precede coronary artery disease. In addition, silent myocardial ischemia (SMI) is more common in diabetic patients and is a strong predictor of cardiac events and death.

AIM

To evaluate the presence of SMI in patients with diabetes and ED using multidetector computed tomographic coronary angiography (MDCT-CA).

METHODS

This study evaluated patients with diabetes and ED without any history of cardiac symptoms or signs. Erectile function was evaluated with the Sexual Health Inventory for Men score, erection hardness score (EHS), and maximal penile circumferential change by an erectometer. MDCT-CA was used for the detection of coronary artery stenosis.

MAIN OUTCOME MEASURES

Sexual Health Inventory for Men score, EHS, maximal penile circumferential change, and coronary artery stenosis by MDCT-CA.

RESULTS

Of 20 patients (mean age = 61.45 ± 10.7 years), MDCT-CA showed coronary artery stenosis in 13 (65%) in the form of one-vessel disease (n = 6, 30%), two-vessel disease (n = 2, 10%), and three-vessel disease (n = 5, 25%). Fifty percent of patients showed at least 50% vessel lumen obstruction of the left anterior descending coronary artery, which was the most commonly affected vessel (55%). Fifteen percent (3 of 20) of patients had greater than 90% stenosis, and two of them underwent an immediate coronary angioplasty with stenting to prevent myocardial infarction. Maximum coronary artery stenosis was positively correlated with age (P = 0.016, r = 0.529) and negatively correlated with EHS (P = .046, r = -0.449). Multivariate regression analysis using age and EHS showed that age was the only independent predictor of SMI (P = .04).

CONCLUSION

MDCT-CA can be a useful tool to identify SMI in diabetic patients with ED, especially in those of advanced age and/or with severe ED.

Subclinical Vascular Disease and Subsequent Erectile Dysfunction: The Multiethnic Study of Atherosclerosis (MESA)

BACKGROUND

The association between subclinical cardiovascular disease and subsequent development of erectile dysfunction (ED) remains poorly described.

HYPOTHESIS

Among multiple subclinical atherosclerosis and vascular dysfunction measurements, coronary artery calcium (CAC) score best predicts ED.

METHODS

After excluding participants taking ED medications at baseline, we studied 1862 men age 45 to 84 years free of known cardiovascular disease from the Multi-Ethnic Study of Atherosclerosis (MESA) with comprehensive baseline subclinical vascular disease phenotyping and ED status assessed at MESA visit 5 (9.4 ± 0.5 years after baseline) using a standardized question on ED symptoms. Multivariable logistic regression was used to assess the associations between baseline measures of vascular disease (atherosclerosis domain: CAC, carotid intima-media thickness, carotid plaque, ankle-brachial index; vascular stiffness/function domain: aortic stiffness, carotid stiffness, brachial flow-mediated dilation) and ED symptoms at follow-up.

RESULTS

Mean baseline age was 59.5 ± 9 years, and 839 participants (45%) reported ED symptoms at follow-up. Compared with symptom-free individuals, participants with ED had higher baseline prevalence of CAC score >100 (36.4% vs 17.2%), carotid intima-media thickness Z score >75th percentile (35.3% vs 16.6%), carotid plaque score ≥2 (39% vs 21.1%), carotid distensibility <25th percentile (34.6% vs 17.1%), aortic distensibility <25th percentile (34.2% vs 18.7%), and brachial flow-mediated dilation <25th percentile (28.4% vs 21.3%); all P < 0.01. Only CAC >100 (odds ratio: 1.43, 95% confidence interval: 1.09-1.88) and carotid plaque score ≥2 (odds ratio: 1.33, 95% confidence interval: 1.02-1.73) were significantly associated with ED.

CONCLUSIONS

Subclinical vascular disease is common in men who later self-report ED. Early detection of subclinical atherosclerosis, particularly advanced CAC and carotid plaque, may provide opportunities for predicting the onset of subsequent vascular ED.

Cardiovascular Disease Prevention in Men with Vascular Erectile Dysfunction: The View of the Preventive Cardiologist

Vascular erectile dysfunction is a powerful marker of increased cardiovascular risk. However, current guidelines lack specific recommendations on the role that the evaluation of vascular erectile dysfunction should play in cardiovascular risk assessment, as well on the risk stratification strategy that men with vascular erectile dysfunction should undergo. In the last 3 years, erectile dysfunction experts have made a call for more specific guidance and have proposed the selective use of several prognostic tests for further cardiovascular risk assessment in these patients. Among them, stress testing has been prioritized, whereas other tests are considered second-line tools. In this review, we provide additional perspective from the viewpoint of the preventive cardiologist. We discuss the limitations of current risk scores and the potential interplay between erectile dysfunction assessment and the use of personalized prognostic tools, such as the coronary artery calcium score, in the cardiovascular risk stratification and management of men with vascular erectile dysfunction. Finally, we present an algorithm for primary care physicians, urologists, and cardiologists to aid clinical decision-making.

The Association of Erectile Dysfunction and Cardiovascular Disease: A Systematic Critical Review

Despite strong association between erectile dysfunction (ED) and cardiovascular disease (CVD), there is a paucity of clear clinical guidelines detailing when and how to evaluate for ED in patients with known CVD, or vice versa. This systematic 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. A comprehensive literature review utilizing MEDLINE®, the Cochrane Library® Central Search, and the Web of Science was performed to identify all published peer-reviewed articles in the English language describing ED and CVD across various disciplines. There is strong consensus that men with ED should be considered at high risk of CVD. Available risk assessment tools should be used to stratify the coronary risk score in each patient. The 2012 Princeton III Consensus Conference expanded on existing cardiovascular recommendations, proposing an approach to the evaluation and management of cardiovascular risk in men with ED and no known CVD. This systematic review highlights the similarities and differences of the existing clinical guidelines and recommendations regarding assessment and management of ED and CVD, as well as the pathophysiological linkage between ED and CVD, which may permit physicians, including urologists, to perform opportunistic screening and initiate secondary prophylaxis with regard to cardiovascular risk factors, particularly in young, nondiabetic men with ED.

Association between serum fetuin-A level and erectile function

Recent studies have shown that ED is an early symptom of atherosclerosis. Fetuin-A, a glycoprotein secreted by the liver, kidneys and choroid plexus, has been linked to systemic fibrosis and calcification in human and rat studies. Deficiency of this compound may play a role in atherosclerosis and cardiovascular disease progression. The aim of the study was to examine whether serum fetuin-A level is related to erectile function or severity of ED. Sixty ED patients without cardiovascular disease were assigned to one of the three groups (mild, moderate or severe ED) depending on ED severity. Twenty healthy volunteers were included as the control group. The International Index of Erectile Function-5 questionnaire was used to measure erection quality in all four groups. Mean age, body mass index, total testosterone, low- and high-density lipoprotein cholesterol, and triglyceride levels did not significantly differ between the three erectile dysfunction and control groups (P > 0.05). The group with severe ED had a significantly lower mean fetuin-A level than the mild ED and control groups. For both mild and moderate ED groups, the mean serum fetuin-A level was significantly lower in comparison with the control group (P < 0.001). Serum fetuin-A level may be used as a supplemental biochemical parameter in preliminary evaluation of ED.

Relationship between pseudoexfoliation syndrome and erectile dysfunction: a possible cause of endothelial dysfunction for development of erectile dysfunction

Objectives:

Pseudoexfoliation syndrome (PES) is a common age-related fibrillopathy related to accumulation of pseudoexfoliation material (PEM) in certain places in the body, especially blood vessels. Erectile dysfunction (ED) is another condition related to vascular pathology and in this study it is aimed to identify the relationship between ED and PES.

Materials and Methods:

Data of 92 patients were investigated. There were 34 patients in the PES group and 58 patients in the control group. Presence of diabetes, hypertension, smoking history, BMI, and serum levels of lipids and testosterone were recorded. The groups were compared for ED rates and severity. Also logistic regression analysis was performed to identify independent risk factors for development of ED.

Results:

Mean age of the population was 67.3. No significant difference was observed between the two groups regarding the presece of DM, HT, smoking, BMI and laboratory measurements. ED rate was significantly higher in the PES group (70.6% vs 48.3%, p=0.002). Also, severe ED rate was higher in the PES group (p=0.002). PES was detected as an independent risk factors for the development of ED.

Conclusion:

ED is a possible consequence of PES. ED rate and severity is found to be higher in the PES group and PES is detected as an independent risk factor for development of ED. Patients with PES should be informed about development of ED and further prospective trials with objective measurements of penile blood flow should be conducted to verify the erectile status and penile blood fow in PES patients.

A systematic review of the association between erectile dysfunction and cardiovascular disease

CONTEXT

Erectile dysfunction (ED) is considered a vascular impairment that shares many risk factors with cardiovascular disease (CVD). A correlation between ED and CVD has been hypothesized, and ED has been proposed as an early marker of symptomatic CVD.

OBJECTIVE

To analyze the relationship between ED and CVD, evaluating the pathophysiologic links between these conditions, and to identify which patients would benefit from cardiologic assessment when presenting with ED.

EVIDENCE ACQUISITION

A systematic literature review searching Medline, Embase, and Web of Science databases was performed. The search strategy included the terms erectile dysfunction, cardiovascular disease, coronary artery disease, risk factors, pathophysiology, atherosclerosis, low androgen levels, inflammation, screening, and phosphodiesterase type 5 inhibitors alone or in combination. We limited our search to studies published between January 2005 and May 2013.

EVIDENCE SYNTHESIS

Several studies reported an association between ED and CVD. The link between these conditions might reside in the interaction between androgens, chronic inflammation, and cardiovascular risk factors that determines endothelial dysfunction and atherosclerosis, resulting in disorders of penile and coronary circulation. Because penile artery size is smaller compared with coronary arteries, the same level of endothelial dysfunction causes a more significant reduction of blood flow in erectile tissues compared with that in coronary circulation. Thus ED could be an indicator of systemic endothelial dysfunction. From a clinical standpoint, because ED may precede CVD, it can be used as an early marker to identify men at higher risk of CVD events. ED patients at high risk of CVD should undergo detailed cardiologic assessment and receive intensive treatment of risk factors.

CONCLUSIONS

ED and CVD should be regarded as two different manifestations of the same systemic disorder. ED usually precedes CVD onset, and it might be considered an early marker of symptomatic CVD.

Relationship between erectile dysfunction and silent coronary artery disease: detection with multidetector computed tomography coronary angiography

AIM

Our aim was to determine the relationship between erectile dysfunction (ED) and silent coronary artery disease (CAD) by multidetector computed tomography (MDCT) coronary angiography.

METHODS

Thirty consecutive men with nonhormonal and nonpsychogenic ED and with no cardiac symptoms were evaluated. Medical history, physical examination and laboratory investigation were performed. The five-item brief form of the International Index of Erectile Function (IIEF-5) was performed for evaluation of ED. The Agatston score (AS) was determined from MDCT images under beta blockade to induce bradycardia. The MDCT coronary angiography findings were evaluated by two radiologists blinded to the clinical findings. Patients were classified into three categories (mild, moderate and severe ED) according to IIEF-5 scores and into five categories (very low, low, moderate, moderately high and high CAD risk) according to the AS.

RESULTS

Mean age was 58.3 ± 8.7 years (46-79). 6 patients had hypertriglyceridemia, 4 had hypercholesterolemia and 4 had hyperglycemia. All patients had normal early morning testosterone levels. Regarding IIEF-5 scores, none of them had mild ED, 14 had moderate ED and 16 had severe ED. Of the 14 patients with moderate ED, 21.4% had low and 28.5% had moderate CAD risk regarding AS. Of the 16 patients with severe ED, 25% had moderate, 31.2% had moderately high and 25% had high CAD risk regarding AS. Increasing age was a risk factor for high AS (p = 0.045). There was a significant correlation between AS and ED severity (p = 0.01).

CONCLUSIONS

ED and CAD often coexist. MDCT coronary angiography can detect coronary lesions and allow appropriate medical intervention.

Nitric oxide-mediated coronary flow regulation in patients with coronary artery disease: recent advances

Nitric oxide (NO) formed via endothelial NO synthase (eNOS) plays crucial roles in the regulation of coronary blood flow through vasodilatation and decreased vascular resistance, and in inhibition of platelet aggregation and adhesion, leading to the prevention of coronary circulatory failure, thrombosis, and atherosclerosis. Endothelial function is impaired by several pathogenic factors including smoking, chronic alcohol intake, hypercholesterolemia, obesity, hyperglycemia, and hypertension. The mechanisms underlying endothelial dysfunction include reduced NO synthase (NOS) expression and activity, decreased NO bioavailability, and increased production of oxygen radicals and endogenous NOS inhibitors. Atrial fibrillation appears to be a risk factor for endothelial dysfunction. Endothelial dysfunction is an important predictor of coronary artery disease (CAD) in humans. Penile erectile dysfunction, associated with impaired bioavailability of NO produced by eNOS and neuronal NOS, is also considered to be highly predictive of ischemic heart disease. There is evidence suggesting an important role of nitrergic innervation in coronary blood flow regulation. Prophylactic and therapeutic measures to eliminate pathogenic factors inducing endothelial and nitrergic nerve dysfunction would be quite important in preventing the genesis and development of CAD.

Effect of atorvastatin on erectile functions in comparison with regular tadalafil use. A prospective single-blind study

OBJECTIVES

Erectile dysfunction (ED) is a common problem for elderly males. Higher serum lipid levels have important role in the pathogenesis, and in this prospective randomized trial, it is aimed to identify the effect of atorvastatin on erectile functions in comparison with regular tadalafil use.

MATERIALS AND METHODS

120 patients with a minimum 3-months history of moderate-to-severe ED were involved. The patients were randomized to receive atorvastatin 10 mg/day, tadalafil 20 mg 3 times/week or no medication. Baseline serum testosterone, lipid levels IEEF and NPT test were performed and repeated after 3 months of treatment, and the 3 groups were compared.

RESULTS

Mean age of the whole population was 56 years (31-70). The 3 groups were well balanced for the baseline characteristics. Mean improvement of IIEF score was significantly higher in tadalafil group compared to atorvastatin (P = 0.01) and control group (P = 0.0001). Also atorvastatin showed significantly better improvement compared to control group (P = 0.001). Positive NPT test results in tadalafil group was significantly higher than atorvastatin group (25/40 (62.5%) vs. 16/41 (39%), P = 0.003) and compared to control group (25/40 (62.5%) vs. 3/39 (7.6%), P = 0.0001). At the same time, the difference between group 1 and group 3 was statistically significant (P = 0.001).

CONCLUSION

Tadalafil 20 mg three times/week shows better results than 10 mg atorvastatin daily. Atorvastatin alone seems to improve EF compared to not using any medication, and this significance is more prominent in patients with supranormal serum lipid levels. Further studies with subgroups of different serum lipid levels should be conducted.

Coronary artery calcium scoring and its impact on the clinical practice in the era of multidetector CT

With the suggestion of coronary artery calcium as an indicator of coronary artery disease 30 years ago, intense and controversial discussion regarding coronary artery calcium has been ongoing. Diverse techniques for evaluation of coronary artery calcium were suggested and validation of its feasibility has been followed up. Following establishment of reference standards, coronary artery calcium became widely utilized in clinical practice and scientific research. Originally coronary artery calcium scoring techniques were developed for prediction of cardiovascular risk. Additionally, coronary artery calcium scoring has been utilized as an indicator for other medical events. Recently, coronary artery calcium scoring used to be applied as a reference standard during scientific research. In this article, the topic of coronary artery calcium, from its introduction to its current usefulness, was discussed from the viewpoints of coronary artery calcium scoring techniques, imaging modalities, validation of the techniques, clinical feasibility of coronary artery calcium scoring beyond traditional cardiovascular risk prediction, and utilization of coronary artery calcium scoring as a reference standard. Popular coronary calcium scoring techniques comprises of Agatston, volume, and mass scores. Through validation of these techniques, pros and cons of each technique were analyzed and proper utility could be suggested. In parallel, the reference standards for Agatston and volume scores were established by age, sex, and race. Through the vigorous controversies, nowadays, the clinical feasibility of coronary artery calcium score as a surrogate marker of cardiovascular risk was acknowledged in the literature.

Erectile dysfunction and testosterone screening with prostate specific antigen screening at age 40: are these three gender specific determinants additive for overall men's heath and do they improve traditional non-gender specific determinants to lessen cardiovascular risk and all-cause mortality?

AIMS

Assess support for a recommendation to add screening for both erectile dysfunction (ED) and hypogonadism to the initial medical evaluation of young-to-middle aged (≥ 40 years of age) men in light of recent guidelines suggesting prostate-specific antigen screening occur at that age.

METHODS

A search of literature published from 1998 to 2009 was performed. Search terms included: ED combined with coronary artery disease (CAD), metabolic syndrome and hypogonadism, hypogonadism and ED, hypogonadism, ED and mortality. Articles were evaluated according to the Center of Evidence-Based Medicine.

RESULTS

Both retrospective and prospective evaluations have demonstrated a strong relationship between ED, established cardiovascular risk factors, CAD and the potential occurrence of cardiovascular events. Low testosterone levels are associated with ED. Low serum total testosterone is an independent risk factor for both metabolic syndrome and type 2 diabetes and all-cause mortality.

CONCLUSION

Traditionally, ED and testosterone levels have been considered mainly, if not exclusively, in the context of sexual health. The results briefly summarised herein and other recent reviews suggest that ED and hypogonadism are signals of future all-cause mortality and overall health status and thus move these evaluations into the broader arena of public health. Screening for ED and hypogonadism provide 'gender-specific determinants' to assess general metabolic and cardiovascular health risks in men. It is the opinion of the authors that this screening be performed in addition to the well-established non-gender-specific screening tests of lipids, blood pressure, obesity and serum glucose.

Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus

* A significant proportion of men with erectile dysfunction (ED) exhibit early signs of coronary artery disease (CAD), and this group may develop more severe CAD than men without ED (Level 1, Grade A). * The time interval among the onset of ED symptoms and the occurrence of CAD symptoms and cardiovascular events is estimated at 2-3 years and 3-5 years respectively; this interval allows for risk factor reduction (Level 2, Grade B). * ED is associated with increased all-cause mortality primarily due to increased cardiovascular mortality (Level 1, Grade A). * All men with ED should undergo a thorough medical assessment, including testosterone, fasting lipids, fasting glucose and blood pressure measurement. Following assessment, patients should be stratified according to the risk of future cardiovascular events. Those at high risk of cardiovascular disease should be evaluated by stress testing with selective use of computed tomography (CT) or coronary angiography (Level 1, Grade A). * Improvement in cardiovascular risk factors such as weight loss and increased physical activity has been reported to improve erectile function (Level 1, Grade A). * In men with ED, hypertension, diabetes and hyperlipidaemia should be treated aggressively, bearing in mind the potential side effects (Level 1, Grade A). * Management of ED is secondary to stabilising cardiovascular function, and controlling cardiovascular symptoms and exercise tolerance should be established prior to initiation of ED therapy (Level 1, Grade A). * Clinical evidence supports the use of phosphodiesterase 5 (PDE5) inhibitors as first-line therapy in men with CAD and comorbid ED and those with diabetes and ED (Level 1, Grade A). * Total testosterone and selectively free testosterone levels should be measured in all men with ED in accordance with contemporary guidelines and particularly in those who fail to respond to PDE5 inhibitors or have a chronic illness associated with low testosterone (Level 1, Grade A). * Testosterone replacement therapy may lead to symptomatic improvement (improved wellbeing) and enhance the effectiveness of PDE5 inhibitors (Level 1, Grade A). * Review of cardiovascular status and response to ED therapy should be performed at regular intervals (Level 1, Grade A).

The association of glomerular filtration rate and erectile dysfunction with severity of coronary artery disease in patients presenting with chest pain

BACKGROUND

The most common cause of death in patients with chronic kidney disease is cardiovascular. Coexistence of reduced estimated glomerular filtration rate (eGFR) and erectile dysfunction (ED) may predate severe underlying coronary artery disease (CAD). The aim of this study was to evaluate the predictive value of presence and severity of ED and reduced estimated eGFR in the risk stratification of CAD in patients with chest pain.

METHODS

Two hundred and sixty-five consecutive male patients with chest pain were included. All patients underwent exercise stress test (EST), of whom those with positive EST underwent coronary angiography. eGFR was calculated and sexual health inventory for men (SHIM) form was applied to evaluate ED. The relation between SHIM scores, eGFR and the number of arteries with significant lesions was evaluated.

RESULTS

Of the 265 male patients, 105 had positive EST while the remaining 160 patients had negative EST. ED was present in 62 patients (38.8%) in the EST (-) group and in 64 patients (61%) in the EST (+) group (P = 0.000). In the EST (+) group, coronary angiography (CAG) revealed normal coronary anatomy or insignificant coronary lesions in 19 (18%), one-vessel disease in 45 (43%), two-vessel disease in 22 (21%) and three-vessel disease in 19 (18%) patients, respectively. The lowest ED prevalence (36.8%) was seen in patients who had normal coronary anatomy or insignificant coronary lesions while the highest prevalence was in those with three-vessel disease (89.5%). When eGFR were taken into account, there was a significant difference between the groups as well (107.2 ± 19.2 ml/min in the EST (-) group versus 94.1 ± 20.0 ml/min in the EST (+) group; P = 0.001).

CONCLUSION

The presence and severity of ED and reduced eGFR are associated with the severity of underlying CAD in patients presenting with chest pain, and they could be implemented in the risk stratification of these patients.

Erectile dysfunction as a predictor for subsequent atherosclerotic cardiovascular events: findings from a linked-data study

INTRODUCTION

In spite of the mounting interest in the nexus between erectile dysfunction (ED) and cardiovascular (CV) diseases, there is little published information on the role of ED as a predictor for subsequent CV events.

AIM

This study aimed to investigate the role of ED as a predictor for atherosclerotic CV events subsequent to the manifestation of ED. Method. The investigation involved the retrospective study of data on a cohort of men with ED linked to hospital morbidity data and death registrations. By using the linked data, the incidence rates of atherosclerotic CV events subsequent to the manifestation of ED were estimated in men with ED and no atherosclerotic CV disease reported prior to the manifestation of ED. The risk of subsequent atherosclerotic CV events in men with ED was assessed by comparing these incidence rates with those in the general male population.

MAIN OUTCOME MEASURE

Standardized incidence rate ratio (SIRR), comparing the incidence of atherosclerotic CV events subsequent to the manifestation of ED in a cohort of 1,660 men with ED to the incidence in the general male population.

RESULTS

On the basis of hospital admissions and death registrations, men with ED had a statistically significantly higher incidence of atherosclerotic CV events (SIRR 2.2; 95% confidence interval 1.9, 2.4). There were significantly increased incidence rate ratios in all age groups younger than 70 years, with a statistically highly significant downward trend with increase of age (P < 0.0001) across these age groups. Younger age at first manifestation of ED, cigarette smoking, presence of comorbidities and socioeconomic disadvantage were all associated with higher hazard ratios for subsequent atherosclerotic CV events.

CONCLUSIONS

The findings show that ED is not only significantly associated with but is also strongly predictive of subsequent atherosclerotic CV events. This is even more striking when ED presents at a younger age.