Erectile dysfunction severity as a risk marker for cardiovascular disease hospitalisation and all-cause mortality: a prospective cohort study

Proceedings of PRINCETON IV: PDE5 inhibitors and cardiac health symposium

INTRODUCTION

Prior consensus meetings have addressed the relationship between phosphodiesterase type 5 (PDE5) inhibition and cardiac health. Given significant accumulation of new data in the past decade, a fourth consensus conference on this topic was convened in Pasadena, California, on March 10 and 11, 2023.

OBJECTIVES

Our meeting aimed to update existing knowledge, assess current guidelines, and make recommendations for future research and practice in this area.

METHODS

An expert panel reviewed existing research and clinical practice guidelines.

RESULTS

Key findings and clinical recommendations are the following: First, erectile dysfunction (ED) is a risk marker and enhancer for cardiovascular (CV) disease. For men with ED and intermediate levels of CV risk, coronary artery calcium (CAC) computed tomography should be considered in addition to previous management algorithms. Second, sexual activity is generally safe for men with ED, although stress testing should still be considered for men with reduced exercise tolerance or ischemia. Third, the safety of PDE5 inhibitor use with concomitant medications was reviewed in depth, particularly concomitant use with nitrates or alpha-blockers. With rare exceptions, PDE5 inhibitors can be safely used in men being treated for hypertension, lower urinary tract symptoms and other common male disorders. Fourth, for men unresponsive to oral therapy or with absolute contraindications for PDE5 inhibitor administration, multiple treatment options can be selected. These were reviewed in depth with clinical recommendations. Fifth, evidence from retrospective studies points strongly toward cardioprotective effects of chronic PDE5-inhibitor use in men. Decreased rates of adverse cardiac outcomes in men taking PDE-5 inhibitors has been consistently reported from multiple studies. Sixth, recommendations were made regarding over-the-counter access and potential risks of dietary supplement adulteration. Seventh, although limited data exist in women, PDE5 inhibitors are generally safe and are being tested for use in multiple new indications.

CONCLUSION

Studies support the overall cardiovascular safety of the PDE5 inhibitors. New indications and applications were reviewed in depth.

The Princeton IV Consensus Recommendations for the Management of Erectile Dysfunction and Cardiovascular Disease

The Princeton Consensus (Expert Panel) Conference is a multispecialty collaborative symposium dedicated to optimizing sexual function and preserving cardiovascular health. The Fourth Princeton Consensus Conference was convened on March 10-11, 2023, at the Huntington Medical Research Institutes in Pasadena, California. Princeton panels I to III addressed the clinical management of men with erectile dysfunction (ED) who also had cardiovascular disease. Thirteen years since Princeton III, Princeton IV builds on previous foundations in several key areas. Mounting evidence supports the need for providers to treat men with ED as being at risk for cardiac events until proven otherwise. Algorithms for the diagnosis and treatment of ED are updated with new recommendations for coronary artery calcium scoring for advanced cardiovascular risk stratification. Optimization of oral phosphodiesterase type 5 inhibitors in the treatment of men with ED and cardiovascular disease is thoroughly explored, including recent evidence of potential cardioprotective effects of these drugs.

Association between the atherogenic index of plasma and erectile dysfunction in US men: a population-based cross-sectional study

Erectile dysfunction (ED) is associated with cardiovascular disease (CVD) and involves risk factors such as atherosclerosis and endothelial dysfunction. Since the atherogenic index of plasma (AIP) may be potentially valuable in predicting cardiovascular risk, we conducted a comprehensive analysis of the relationship between AIP and ED using large-scale data, as well as exploring its potential implications for clinical and future research. We screened the National Health and Nutrition Examination Survey (NHANES) database using R software, selected datasets from two study cycles for cross-sectional analysis, enrolled covariates and performed statistical analyses using multivariate logistic regression. Furthermore, sensitivity analyses were performed and the relationship between the AIP index and ED was further assessed using generalized additive model regression and smoothed curve fitting. After an initial filter of 21,161 participants, 1503 participants were included, and the AIP level in the ED group was 0.21 ± 0.02 compared with 0.08 ± 0.01 in the group without ED, which was analyzed to show a statistically significant difference between them (P < 0.0001), and the difference was further confirmed in the sensitivity analyses. We suggest that early assessment, intervention, and individualized treatment of ED in people with high AIP levels is warranted, as it not only improves sexual function but also reduces the risk of CVD. However, it was a limitation of this study that the study population was all from the US, and more research is needed in the future to elucidate the causal relationship between AIP and ED and the association in a wider population.

Genetic and causal relationship between chronic gastrointestinal diseases and erectile dysfunction: a Mendelian randomization study

Background

Studies based on observations have indicated potential associations between chronic gastrointestinal diseases and an increased risk of erectile dysfunction (ED). However, the causality of these connections remains ambiguous.

Methods

Summary data for chronic gastrointestinal diseases were extracted from public data. Summary data on ED were extracted from three distinct sources. The genetic correlations between chronic gastrointestinal diseases and ED were explored using linkage disequilibrium score regression (LDSC). The causal associations between chronic gastrointestinal diseases and ED were evaluated using Mendelian randomization (MR) analysis, followed by a meta-analysis to determine the ultimate causal effect.

Results

The LDSC results suggested significant genetic correlations between Crohn's disease (CD) and ED. Inflammatory bowel disease (IBD), ulcerative colitis (UC), and liver cirrhosis (LC) were found to have potential genetic correlations with ED. The combined multiple MR results indicate that IBD and CD have significant causal relationships with ED, while colorectal cancer (CRC) may have a potential causal effect on ED.

Conclusion

This research provided evidence supporting a causal association between IBD, CD, CRC, and ED. The impact of chronic gastrointestinal diseases on ED warrants greater attention in clinical practice.

Association between erectile dysfunction and the prevalence and prognosis of hyperglycemia in adults in the USA based on NHANES 2001-2004

Prior research has demonstrated that erectile dysfunction (ED) is a significant risk factor for cardiovascular disease (CVD) and premature mortality. Few studies have examined the link between ED and hyperglycemia, and the predictive power of ED for mortality in individuals with hyperglycemia. A cohort of 1584 adults diagnosed with hyperglycemia, consisting of 583 individuals with diabetes and 1001 individuals with prediabetes, was selected from the National Health and Nutrition Examination Survey (NHANES) conducted between 2001 and 2004. The study found a positive correlation between severe ED and hyperglycemia (OR, 2.03; 95% CI 1.53-2.68), while no significant relationship was observed between severe ED and CVD events (OR, 1.60; 95% CI 0.91-2.80). Additionally, no statistical association was found between diabetes or prediabetes status and ED. After multivariable adjustments, severe ED was found to be significantly associated with an increased risk of all-cause mortality (HR, 1.67; 95% CI 1.16-2.39), while no significant association was observed between severe ED and CVD mortality (HR, 1.92; 95% CI 0.92-3.98). Our study indicates a significant correlation between ED and hyperglycemia status. Hyperglycemia Individuals with ED generally exhibited an unfavorable prognosis for mortality due to all causes and CVD, particularly among those with low levels of physical activity.

Relationship between dietary niacin intake and erectile dysfunction: a population-based study

Existing research on the precise link between dietary niacin intake and erectile dysfunction (ED) is scarce. Thus, this study aimed to investigate the potential association between dietary niacin intake and the risk of ED. Multivariate logistic regression and restricted cubic splines (RCSs) were used to examine the relationship between dietary niacin intake and ED. Subgroup interaction analysis was performed to assess the impact of different subgroups on the study outcomes. In addition, 1:1 propensity score matching (PSM) was employed to adjust for potential confounding factors, ensuring the reliability of the results. The analyzed data were collected from the 2001-2004 National Health and Nutrition Examination Survey (NHANES) in the USA. The study encompassed 3184 adults, among whom 863 participants were identified as having ED. Following adjustments for potential confounders, the findings revealed that higher niacin intake, specifically in the highest tertile, was associated with a decreased risk of ED compared to that in the lowest tertile, showing an odds ratio (OR) of 0.56 (95% confidence interval [CI]: 0.37-0.85). Analysis of dose-response curves illustrated a negative correlation between dietary niacin intake and the risk of ED. Subgroup and interaction analyses fortified the consistency of these results. Furthermore, PSM corroborated the validity of the findings. This study suggests an inverse association between dietary niacin intake and the risk of ED. However, establishing a cause-and-effect relationship remains elusive, and defining the safe threshold of niacin intake to prevent ED requires further investigation.

Association between cardiometabolic index and erectile dysfunction among US adults: a cross-sectional analysis of the National Health and Nutrition Examination Survey 2001-2004

The aim of this study was to assess the association between a new metabolic index, the cardiometabolic index (CMI) and erectile dysfunction (ED). The data for this study relied on the National Health and Nutrition Examination Survey (NHANES), a cross-sectional database, between 2001 and 2004. The CMI was calculated as the following formula: Triglyceride (TG) (mmol/L)/ High density lipid-cholesterol (HDL-C) (mmol/L) ×waist-height ratio (WHtR). The multivariate logistic regression analyses were conducted to assess the association between CMI and ED, supplemented by subgroup analysis and dose-response curves. Finally, a total of 1367 adult male participants were identified, and the mean CMI was 0.83 ± 0.02. Multivariate logistic regression analysis showed that in model 2 controlling for all potential confounders, CMI was significantly associated with ED (OR = 1.49, 95% CI: 1.09, 2.04) (p = 0.017). Subsequently, we convert the CMI from a continuous variable to a categorical variable (Tertiles). The results showed that male participants in CMI Tertile 3 group had a higher risk of ED than those in Tertile 1 group in model 2 (OR = 2.07, 95% CI: 1.12, 3.83, P = 0.024). The subgroup analysis of model 2 demonstrated that CMI was significantly associate with ED in participants aged ≥50 y (OR = 2.31, 95% CI: 1.35, 3.95, P = 0.005), body mass index (BMI) > 30 kg/m2 (OR = 1.78, 95% CI: 1.10, 2.90, P = 0.023), with hypertension (OR = 1.89, 95% CI: 1.63, 3.45, P = 0.020), with diabetes mellitus (OR = 1.67, 95% CI: 1.13, 2.47, P = 0.015), with cardiovascular disease (CVD) (OR = 1.54, 95% CI: 1.12, 2.10, P = 0.011) and smoking (OR = 2.07, 95% CI: 1.26, 3.39, P = 0.007). This study demonstrates a strong association between CMI and ED and an increased risk of ED with higher CMI levels. More prospective studies with large samples and good designs are needed to validate our results in the future.

The effect of three years of vitamin D supplementation on erectile dysfunction: Results from the randomized placebo-controlled D-Health Trial

BACKGROUND & AIMS

Erectile dysfunction is common among older men and has been associated with low serum 25-hydroxy vitamin D concentration. However, this association may be due to uncontrolled confounding, and there is a paucity of evidence from interventional studies. We aimed to examine the effect of vitamin D supplementation on the prevalence of erectile dysfunction, in an exploratory analysis using data from a large randomized controlled trial.

METHODS

The D-Health Trial recruited Australians aged 60-84 years between January 2014 and May 2015 and randomly assigned them to supplementation with 60,000 IU of vitamin D or placebo per month for up to 5 years. Blood samples were collected annually from randomly selected participants (total N = 3943). We assessed erectile dysfunction at the end of the third year of follow-up. We used log-binomial regression to examine the effect of vitamin D on the prevalence of erectile dysfunction overall, and within sub-groups.

RESULTS

Of the 11,530 men enrolled, 8920 (77.4 %) completed the erectile dysfunction question and were included in the analysis. After three years of supplementation, the mean serum 25-hydroxy vitamin D concentration was 76 nmol/L (standard deviation (SD) 24.94) in the placebo group and 106 nmol/L (SD 26.76) in the vitamin D group (p < 0.0001). The prevalence of erectile dysfunction was 58.8 % and 59.0 % in the vitamin D and placebo groups, respectively (prevalence ratio 1.00, 95 % CI 0.97, 1.03); there was no evidence of an effect of vitamin D in any subgroup analyses.

CONCLUSION

Supplementing older men with vitamin D is unlikely to prevent or improve erectile dysfunction.

CLINICAL TRIALS REGISTRY

(ACTRN12613000743763).

Mapping the APOE structurally on missense variants in elderly Brazilians

Cardiovascular diseases (CVDs) pose a significant global health threat, with familial hypercholesterolemia (FH) being a key genetic contributor. The apolipoprotein E (APOE) gene plays a vital role in lipid metabolism, and its variants are associated with CVD risk. This study explores prevalent APOE variants (p.R163C, p.R176C, p.R246C and p.V254E) using genetic and structural analyses. The research, initiated by identifying high-frequency APOE variants through the ABraOM database, utilizes homology modeling and molecular dynamics (MD) simulations to understand the structural consequences. The major lipid-binding region, a critical domain for lipid metabolism, was a focal point. Structural dynamics, including principal component analyses and domain movement analyses, highlighted distinct patterns in APOE variants compared to the wild type (WT). Results revealed significant differences in the structural behavior of variants, particularly in the Major lipid-binding region. The identification of an 'elbow' structure with two states (Elbow I and Elbow II) provided insights into conformational changes. Notably, variants exhibited unique patterns in hydrogen bonding (hb) and hydrophobic interactions, indicating potential functional consequences. The study further associated APOE variants with clinical outcomes, including cognitive impairment and cholesterol levels. Specific variants demonstrated correlations with cognitive decline and variations in lipid profiles, emphasizing their relevance to cardiovascular and neurobiological health. In conclusion, this integrated approach enhances our understanding of APOE variants, shedding light on their role in lipid metabolism and cardiovascular health. The identified structural 'elbows' and their association with clinical outcomes offer a nuanced perspective, guiding future research toward targeted interventions for diseases linked to lipid metabolism and neurobiology.Communicated by Ramaswamy H. Sarma.

Galectin-3 is involved in inflammation and fibrosis in arteriogenic erectile dysfunction via the TLR4/MyD88/NF-κB pathway

Galectin-3 (Gal-3) is a multifunctional protein that has been linked to fibrosis and inflammation in the cardiovascular system. In this study, we examined the impact of Gal-3 on inflammation and fibrosis in patients with arteriogenic erectile dysfunction (A-ED) and the underlying mechanisms involved. To induce arterial injury, we utilized cuffs on the periaqueductal common iliac arteries of Sprague‒Dawley (SD) rats and administered a high-fat diet to co-induce local atherosclerosis. Our results showed that we successfully developed a novel A-ED model that was validated based on histological evidence. In vivo, the vascular lumen of rats subjected to a high-fat diet and cuff placement exhibited significant narrowing, accompanied by the upregulation of Gal-3, Toll-like receptor 4 (TLR4), and myeloid differentiation primary response protein 88 (MyD88) expression in the penile cavernosa. This led to the activation of nuclear factor kappa B 65 (NF-κB-p65), resulting in reduced intracavernosal pressure, endothelial nitric oxide synthase expression, and smooth muscle content, promoting inflammation and fibrosis. However, treatment with Gal-3 inhibitor-modified citrus pectin (MCP) significantly normalized those effects. In vitro, knocking down Gal-3 led to a significant reduction in TLR4, MyD88, and NF-κB-p65 expression in corpus cavernosum smooth muscle cells (CCSMCs), decreasing inflammation levels. In conclusion, inhibiting Gal-3 may improve A-ED by reducing inflammation, endothelial injury, and fibrosis in the penile corpus cavernosum through the TLR4/MyD88/NF-κB pathway. These findings highlight the potential therapeutic target of Gal-3 in A-ED.

Princeton IV consensus guidelines: PDE5 inhibitors and cardiac health

BACKGROUND

In 1999, 1 year after the approval of the first oral phosphodiesterase type 5 (PDE5) inhibitor for the treatment of erectile dysfunction (ED), the first Princeton Consensus Conference was held to address the clinical management of men with ED who also had cardiovascular disease. These issues were readdressed in the second and third conferences. In the 13 years since the last Princeton Consensus Conference, the experience with PDE5 inhibitors is more robust, and recent new data have emerged regarding not only safety and drug-drug interactions, but also a potential cardioprotective effect of these drugs.

AIM

In March 2023, an interdisciplinary group of scientists and practitioners met for the fourth Princeton Consensus Guidelines at the Huntington Medical Research Institutes in Pasadena, California, to readdress the cardiovascular workup of men presenting with ED as well as the approach to treatment of ED in men with known cardiovascular disease.

METHOD

A series of lectures from experts in the field followed by Delphi-type discussions were developed to reach consensus.

OUTCOMES

Consensus was reached regarding a number of issues related to erectile dysfunction and the interaction with cardiovascular health and phosphodiesterase-5 inhibitors.

RESULTS

An algorithm based on recent recommendations of the American College of Cardiology and American Heart Association, including the use of computed tomography coronary artery calcium scoring, was integrated into the evaluation of men presenting with ED. Additionally, the issue of nitrate use was further considered in an algorithm regarding the treatment of ED patients with coronary artery disease. Other topics included the psychological effect of ED and the benefits of treating it; the mechanism of action of the PDE5 inhibitors; drug-drug interactions; optimizing use of a PDE5 inhibitors; rare adverse events; potential cardiovascular benefits observed in recent retrospective studies; adulteration of dietary supplements with PDE5 inhibitors; the pros and cons of over-the-counter PDE5 inhibitors; non-PDE5 inhibitor therapy for ED including restorative therapies such as stem cells, platelet-rich plasma, and shock therapy; other non-PDE5 inhibitor therapies, including injection therapy and penile prostheses; the issue of safety and effectiveness of PDE5 inhibitors in women; and recommendations for future studies in the field of sexual dysfunction and PDE5 inhibitor use were discussed.

CLINICAL IMPLICATIONS

Algorithms and tables were developed to help guide the clinician in dealing with the interaction of ED and cardiovascular risk and disease.

STRENGTHS AND LIMITATIONS

Strengths include the expertise of the participants and consensus recommendations. Limitations included that participants were from the United States only for this particular meeting.

CONCLUSION

The issue of the intersection between cardiovascular health and sexual health remains an important topic with new studies suggesting the cardiovascular safety of PDE5 inhibitors.

Impact of Fruit and Fruit Juice on Death and Disease Incidence: A Sex-Specific Longitudinal Analysis of 18 603 Adults

BACKGROUND

The health benefits of fruits are well established, but fruit juice has been more controversial. Fruit and juice are often ingested with other foods, which prompted our investigation to determine whether fruit consumed as juice may negate the beneficial effects of consuming whole fruit in people with cardiovascular disease.

METHODS AND RESULTS

We retrospectively analyzed data from a population-based study in Australia (the 45 and Up Study) linked with hospitalization and mortality data up to September 2018. Kaplan-Meier survival estimates and Cox proportional hazards models were used to examine effects of fruit, fruit juice, and the combination of fruit and fruit juice in relation to death and disease incidence among men and women living with cardiovascular disease. A total of 7308 deaths occurred among 18 603 participants diagnosed with cardiovascular disease over a 13-year follow-up. After multivariable adjustment, inadequate fruit intake (hazard ratio [HR], 1.12 [95% CI, 1.01-1.24]) and high fruit juice intake (HR, 1.26 [95% CI, 1.12-1.41]) predicted all-cause mortality in women. Also, high fruit juice intake plus either adequate fruit intake (HR, 1.18 [95% CI, 1.02-1.37]) or inadequate fruit intake (HR, 1.43 [95% CI, 1.21-1.69]) predicted mortality in women. No relationships were found in men after multivariable adjustments. Also, we found no prognostic value for fruit and fruit juice intake on disease incidence.

CONCLUSIONS

In adults with cardiovascular disease, we found that fruit juice (in combination with adequate or inadequate fruit intake) predicted mortality in women but not in men. These effects became less clear when focusing on disease incidence.

Current Advances in Nanotheranostics for Molecular Imaging and Therapy of Cardiovascular Disorders

Cardiovascular diseases (CVDs) refer to a collection of conditions characterized by abnormalities in the cardiovascular system. They are a global problem and one of the leading causes of mortality and disability. Nanotheranostics implies to the combination of diagnostic and therapeutic capabilities inside a single nanoscale platform that has allowed for significant advancement in cardiovascular diagnosis and therapy. These advancements are being developed to improve imaging capabilities, introduce personalized therapies, and boost cardiovascular disease patient treatment outcomes. Significant progress has been achieved in the integration of imaging and therapeutic capabilities within nanocarriers. In the case of cardiovascular disease, nanoparticles provide targeted delivery of therapeutics, genetic material, photothermal, and imaging agents. Directing and monitoring the movement of these therapeutic nanoparticles may be done with pinpoint accuracy by using imaging modalities such as cardiovascular magnetic resonance (CMR), computed tomography (CT), positron emission tomography (PET), photoacoustic/ultrasound, and fluorescence imaging. Recently, there has been an increasing demand of noninvasive for multimodal nanotheranostic platforms. In these platforms, various imaging technologies such as optical and magnetic resonance are integrated into a single nanoparticle. This platform helps in acquiring more accurate descriptions of cardiovascular diseases and provides clues for accurate diagnosis. Advances in surface functionalization methods have strengthened the potential application of nanotheranostics in cardiovascular diagnosis and therapy. In this Review, we have covered the potential impact of nanomedicine on CVDs. Additionally, we have discussed the recently developed various nanoparticles for CVDs imaging. Moreover, advancements in the CMR, CT, PET, ultrasound, and photoacoustic imaging for the CVDs have been discussed. We have limited our discussion to nanomaterials based clinical trials for CVDs and their patents.

Can Erectile Dysfunction Severity Predict Major Adverse Cardiovascular Events in Men Undergoing Dialysis? A Prospective Cohort Study

PURPOSE

To evaluate the impact of severe erectile dysfunction (ED) on future major adverse cardiovascular events (MACE) in men on dialysis.

MATERIALS AND METHODS

This prospective cohort study included 71 men on dialysis. ED was assessed using the Sexual Health Inventory for Men (SHIM). Men were divided into the mild/moderate ED (SHIM score ≥8) and severe ED (SHIM score ≤7) groups. The primary endpoint was MACE-free survival. MACE was a composite of myocardial infarction, cardiovascular death, and stroke. The secondary endpoints were cardiac event-free survival and overall survival (OS). Moreover, the predictive abilities of severe ED for 5-year MACE, 5-year cardiac events, and 5-year overall mortality were evaluated.

RESULTS

The median age and follow-up period of the included men were 64 years and 58 months, respectively. The median SHIM score was 4.0; all had a degree of ED, and 64.7% had severe ED. In the background-adjusted multivariable analyses, severe ED was not significantly associated with shorter MACE-free survival (hazard ratio [HR], 1.890; 95% confidence interval [CI], 0.533-6.706; p=0.324), cardiac event-free survival (HR, 2.081; 95% CI, 0.687-6.304; p=0.195), and OS (HR, 0.817; 95% CI, 0.358-1.863; p=0.630). Severe ED did not significantly improve the predictive abilities for 5-year MACE, 5-year cardiac events, and 5-year overall mortality (p=0.110, p=0.101, and p=0.740, respectively).

CONCLUSIONS

ED severity was not associated with shorter MACE-free survival, cardiac event-free survival, or OS, and ED severity could not improve the predictive abilities for these outcomes in men undergoing dialysis.

Evaluation of bi-directional causal association between periodontal disease and erectile dysfunction: a two-sample Mendelian randomization study

BACKGROUND

The association between periodontal disease (PD) and erectile dysfunction (ED) has been well-documented in observational studies. However, observational studies are vulnerable to reverse causality and confounding factors, making the inference of causal-effect relationships challenging. Contrary to the current belief, Mendelian randomization (MR) can be applied to comprehensively assess the bi-directional causal effects between PD and ED.

METHODS

A two-sample MR analysis was performed using pooled statistics from genome-wide association studies involving European populations with PD (12,289 patients with PD and 22,326 controls) and ED (6,175 patients with clinically diagnosed ED and 217,630 controls). In this MR analysis, three methods--the inverse-variance weighted (IVW) average, weighted median, and MR-Egger regression methods--were used to evaluate the causal relationships between PD and ED.

RESULTS

According to the IVW analysis results, genetically predicted PD did not have a causal effect on ED (odds ratio 1.07, 95% confidence interval 0.96-1.20, p = 0.22). Furthermore, there was no clear indication of a significant causal effect of ED on PD in the reverse MR analysis (odds ratio 0.98, 95% confidence interval 0.90-1.08, p = 0.74). The results of the MR-Egger regression and weighted median methods were consistent with those of the IVW method. Based on the sensitivity analysis results, a major bias from genetic pleiotropy was unlikely to distort the causal estimates.

CONCLUSION

The present study does not support a causal effect between PD and ED.

CLINICAL RELEVANCE

From the perspective of genetics, PD does not appear to be a risk factor for the development of ED.

Identifying potential cross-talk signatures for the occurrence of atherosclerosis in diabetic erectile dysfunction

BACKGROUND

Erectile dysfunction and atherosclerosis are common cardiovascular complications in diseases. Clinical associations between erectile dysfunction and atherosclerosis have been noticed, but the specific mechanisms are not illustrated adequately.

OBJECTIVES

The aim of the study was to further mine associated pathological mechanisms and genetic alterations of atherosclerosis in diabetes mellitus-related erectile dysfunction.

MATERIALS AND METHODS

Significant atherosclerosis-related genes were identified from transcriptome data of diabetes mellitus-related erectile dysfunction and atherosclerosis-related gene sets from DisGeNET and GeneCard databases. Functional enrichment and immune infiltration analyses were performed to clarify the biological roles and pathways as well as immune responses of significant atherosclerosis-related gene sets. A protein-protein interaction network was constructed, and gene clusters were performed. Then, data of diabetic plaques and high-glucose cavernosum endothelial cells were analyzed for validation. And hub atherosclerosis-related gene sets were identified. Finally, expressed pattern of hub atherosclerosis-related gene sets were explored by single-cell profiling and immune analysis.

RESULTS

In total, 202 significant atherosclerosis-related gene sets including 100 upregulated and 102 downregulated genes were identified. These genes were related to endothelial cell migration, inflammatory response, regulation of oxidative stress, and immune response. In immune infiltration, immature dendritic cells and monocytes showed differential expression between the diabetes mellitus-related erectile dysfunction and control groups, A protein-protein interaction network containing 135 nodes was constructed. A hub atherosclerosis-related gene set signature consisting of HBEGF, LOX, NQO1, and VLDLR was obtained by multi-omics validation. In addition, Functional enrichment analysis revealed that hub atherosclerosis-related gene sets were involved in oxidoreductase activity and extracellular matrix organization.

DISCUSSION AND CONCLUSION

We explored atherosclerosis-related genetic changes and signaling pathways in diabetes mellitus-related erectile dysfunction. HBEGF, LOX, NQO1, and VLDLR were identified as hub atherosclerosis-related gene sets. These may serve as potential biomarkers for the clinical management of atherosclerosis and preventing further cardiovascular risks in diabetes mellitus-related erectile dysfunction.

Inflammatory biomarkers may predict response to phosphodiesterase type 5 inhibitor treatment in patients with erectile dysfunction

PURPOSE

In this study, we aimed to evaluate the clinical utility of the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR), and monocyte/high-density lipoprotein cholesterol ratio (MHR) in predicting response to a phosphodiesterase type 5 inhibitor (PDE5i) when used as the first-line medical treatment of erectile dysfunction (ED).

MATERIALS AND METHODS

This study prospectively included 185 patients who were diagnosed with ED and started PDE5i treatment. After PDE5i treatment, 107 (57.8%) patients with an International Index of Erectile Function-5 (IIEF-5) score below 22 were assigned to Group 1, and 78 (42.2%) patients with an IIEF-5 score of 22 or above were assigned to Group 2. The outcome measures of the study were demographic characteristics and inflammation markers between the groups.

RESULTS

The mean IIEF-5 change after PDE5i treatment was 6.1±4.2 points in Group 1 and 11.5±3.2 points in Group 2 (p=0.001). The mean age was 54.6±9.2 years in Group 1 and 47.8±10.3 years in Group 2 (p<0.001), and the median fasting blood glucose values of Groups 1 and 2 were 105 (36) mg/dL and 97 (23) mg/dL, respectively (p=0.010). The LMR and MHR values were 2.39±0.23 and 13.8±7, respectively, for Group 1, and 2.03±0.22 and 17±6.6, respectively, for Group 2 (p=0.044 and p=0.002, respectively). On multivariable analysis, younger age and increased MHR were independent predictors of benefit from PDE5i treatment.

CONCLUSIONS

This study showed that only MHR as an inflammatory biomarker was an independent predictor for response to PDE5i in the treatment of ED. Also, several factors were predictive of treatment failure.

Heterogeneity of fibroblasts is a hallmark of age-associated erectile dysfunction

BACKGROUND

The prevalence of age-associated erectile dysfunction (ED) increases pronouncedly with age. However, the cellular composition and transcriptomic changes of aging penile corpus cavernosum remain largely unclear.

METHODS

Herein, we performed single cell sequencing penile corpus cavernosum from five young with normal erectile response and five old rats with ED.

RESULTS

Clustering analysis identified 19 cell types, such as fibroblasts, myofibroblasts and immune cells. We next revealed their transcriptomic alterations and investigated novel subpopulations of major cell types. Among them, fibroblasts possessed the largest cell number and showed apparent heterogeneity. By performing single-cell entropy analysis on fibroblasts, we observed the age-associated decrease of entropy, and aged fibroblasts were found to adopt senescent secretory phenotype, as evidenced by the high expression of genes associated with the senescence-associated secretory phenotype (SASP). Finally, we constructed a comprehensive intercellular communication network and highlighted key mediators of crosstalk between fibroblasts and other cell types.

CONCLUSIONS

We plotted a cellular atlas of aging cells within penile corpus cavernosum, especially fibroblasts. Our work will deepen the understanding of the heterogeneity among certain cell types within aged penile corpus cavernosum, which will generate positive effects on the future treatment of age-associated ED.

Erectile dysfunction, phosphodiesterase-5 inhibitor use and risk of cardiovascular disease and mortality in people with diabetes: A systematic review and meta-analysis

BACKGROUND

Phosphodiesterase-5 inhibitors (PDE5-Is), used in the management of erectile dysfunction (ED), have potential cardioprotective benefits. The impact of PDE5-Is on reducing adverse cardiovascular outcomes in patients with diabetes mellitus (DM) and ED is uncertain. Using a systematic review and meta-analysis of observational cohort studies and randomised controlled trials (RCTs), we evaluated if (i) the association of PDE5-Is in people with ED and DM and their risk of cardiovascular disease (CVD) and mortality and (ii) ED confers an excess risk of CVD and mortality in patients with DM compared with no DM.

METHODS

Studies were identified from MEDLINE, Embase, the Cochrane Library, Web of Science citation search and search of bibliographies to April 2022. Study-specific risk ratios (RRs) with 95% confidence intervals (CIs) were pooled.

RESULTS

Eighteen unique studies reported on the cardiovascular impact of ED in patients with and without DM. In the general population, the RRs (95% CIs) of ED for composite CVD/MACE, all-cause mortality, CHD and stroke were 1.43 (1.31-1.55), 1.47 (1.31-1.65), 1.59 (1.39-1.82), and 1.34 (1.15-1.56), respectively. The respective estimates were 1.68 (1.15-2.45), 1.40 (0.90-2.18), 1.41 (1.24-1.61) and 1.32 (1.09-1.60) in the diabetes population. Interaction analyses suggested similar risk in both populations. Six studies reported the cardiovascular effects of PDE5-Is in people with ED and DM. Limited RCT data showed no significant differences in the risk of major adverse cardiac event (MACE), coronary heart disease (CHD) and all-cause mortality comparing PDE5-I use with non-use: RRs (95% CIs) of 3.47 (0.17-69.19), 1.31 (0.10-16.54) and 0.35 (0.12-1.05), respectively.

CONCLUSIONS

ED confers no excess risk of CVD and mortality in patients with DM compared with no DM. Limited and inadequately powered data shows no significant differences in the risk of adverse cardiovascular outcomes comparing use of PDE5-Is with non-use in patients with ED and DM. PROSPERO Registration: CRD42022324537.

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 predicts mortality in middle-aged and older men independent of their sex steroid status

BACKGROUND

erectile dysfunction is associated with mortality, whereas the association between low testosterone (T) and higher mortality remains controversial. Sexual dysfunction and low T often coexist, but the relative importance of sexual symptoms versus low T in predicting mortality is not known. We studied the interrelationships between sex steroids and sexual symptoms with all-cause mortality in a large prospective cohort of European men.

DESIGN

survival status was assessed in 1,788 community-dwelling men, aged 40-79, who participated in the European Male Ageing Study (EMAS). Sexual symptoms were evaluated via a validated questionnaire (EMAS-SFQ). Sex steroids were measured by mass spectrometry. Cox proportional hazard models were used to study the association between hormones, sexual symptoms and mortality.

RESULTS

about 420 (25.3%) men died during a mean follow-up of 12.6 ± 3.1 years. Total T levels were similar in both groups, but free T was lower in those who died. Men with three sexual symptoms (erectile dysfunction, reduced morning erections and lower libido) had a higher mortality risk compared with men with none of these symptoms (adjusted hazard ratio (HR) and 95% confidence intervals: 1.75 (1.28-2.40, P = 0.001)). Particularly, erectile dysfunction and poor morning erections, but not lower libido, were associated with increased mortality (HR 1.40 (1.13-1.74, P = 0.002), 1.28 (1.04-1.59, P = 0.023) and 1.12 (0.90-1.39, P = 0.312), respectively). Further adjusting for total T, free T or oestradiol did not influence the observed risk.

CONCLUSIONS

sexual symptoms, in particular erectile dysfunction, predict all-cause mortality independently of sex steroids and can be an early warning sign of a poor health status.

Association Between Chronic Periodontal Disease and Erectile Dysfunction: A Case-Control Study

Erectile dysfunction (ED) and chronic periodontal disease (CPD) share mutual risk factors, and the incidence of ED is increasing among young adults. The relation of CPD and ED remains obscure due to inconsistent clinical evidence. This study aimed to further assess the relationship between CPD and ED using the Community Periodontal Index of Treatment Need (CPITN) and the International Index of Erectile Function (IIEF). Totally, 202 adult men were included, with 100 subjects with ED in the case group and 102 subjects without ED undergoing routine dental examinations in the control group. The IIEF questionnaire was used to assess the severity of ED, and CPD was assessed through the Community Periodontal Index (CPI) score. Periodontal assessments were performed by one single calibrated examiner. Logistic regression analysis was performed for the association between CPD and ED. After adjustment for age, smoking status, tooth brushing time, education level, monthly income, tooth brushing frequency, and gum bleeding, higher CPI score was identified to be associated with a greater risk of ED (odds ratio [OR] = 2.755, 95% confidence interval [CI] = [1.400, 5.423], p = .003), suggesting that CPD was positively associated with the odds of ED. CPD was getting more severe with the progress of ED (p < .05). Men with ED could be encouraged to receive routine dental examinations and appropriate preventive dental measures to maintain oral and periodontal health.

Different Types of Long-Term Milk Consumption and Mortality in Adults with Cardiovascular Disease: A Population-Based Study in 7236 Australian Adults over 8.4 Years

Most studies disregard long-term dairy consumption behaviour and how it relates to mortality. We examined four different types of long-term milk consumption, namely whole milk, reduced fat milk, skim milk and soy milk, in relation to mortality among adults diagnosed with cardiovascular disease (CVD). A retrospective population-based study was conducted in Australia (the 45 and Up Study) linking baseline (2006-2009) and follow-up data (2012-2015) to hospitalisation and mortality data up to 30 September 2018. A total of 1,101 deaths occurred among 7236 participants with CVD over a mean follow-up of 8.4 years. Males (Hazard Ratio, HR = 0.69, 95% CI (0.54; 0.89)) and females (HR = 0.59 (0.38; 0.91)) with long-term reduced fat milk consumption had the lowest risk of mortality compared to counterparts with long-term whole milk consumption. Among participants with ischemic heart disease, males with a long-term reduced fat milk consumption had the lowest risk of mortality (HR = 0.63, 95% CI: 0.43; 0.92). We conclude that among males and females with CVD, those who often consume reduced fat milk over the long-term present with a 31-41% lower risk of mortality than those who often consume whole milk, supporting dairy advice from the Heart Foundation of replacing whole milk with reduced fat milk to achieve better health.

Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs

Sexual health has a fundamental role in overall health and well-being, and a healthy and dynamic sex life can make an important contribution to a good quality of life. Sexual dysfunction, and especially erectile dysfunction (ED) in men, is highly prevalent in patients with cardiovascular disease (CVD). CVD and ED have shared risk factors and pathophysiological links, such as endothelial dysfunction, inflammation and low plasma testosterone levels. ED has been shown to be an independent and early harbinger of future CVD events, providing an important window to initiate preventive measures. Therefore, screening and diagnosing ED is essential for the primary and secondary prevention of CVD because the assessment of ED offers an easy and low-cost prognostic tool that is an alternative to other investigational cardiovascular biomarkers. Moreover, ED is a major contributing factor to the discontinuation of, or poor adherence to, cardiovascular therapy. Cardiovascular drugs have divergent effects on erectile function, with diuretics and β-blockers having the worst profiles, and renin-angiotensin-aldosterone system inhibitors and nebivolol having the best profiles. Pharmacological treatment of ED has an equivocal effect on the risk of CVD, suggesting a complex interaction between ED and drugs for CVD. In this Review, we discuss how sexual function could be incorporated into the patient history taken by physicians treating individuals with CVD, not merely as part of the diagnostic work-up but as a means to pursue tangible and essential benefits in quality of life and cardiovascular outcomes.

The Relationship Between Hematologic Parameters and Erectile Dysfunction

INTRODUCTION

Certain hematologic parameters related to blood cells, known as the biomarkers that predict cardiovascular disease, might be potential predictors of erectile dysfunction (ED) due to the shared pathophysiology between ED and cardiovascular disease .

AIM

To investigate the relationship between ED and these hematologic parameters and the clinical significance of hematologic parameters for the diagnosis of ED.

METHODS

A total of 113 male patients diagnosed with ED were included in this study. Blood samples were collected before 10:00 AM for blood cells examination, biochemical tests, and sex hormone analysis. Another 212 healthy controls without ED from the health management center was included as the control group. The relationship between hematologic parameters and ED was assessed by comparing differences in body mass index (BMI), biochemical indexes and hematologic parameters between the 2 groups, and the diagnostic value of hematologic parameters for ED was also examined and compared.

MAIN OUTCOME MEASURES

International Index of Erectile Function, hematologic parameters RESULTS: The neutrophil count (NC), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) in ED patients were significantly higher than those in healthy controls, whereas the lymphocyte count (LC) was significantly lower than that in healthy controls. After adjusting for age, BMI, uric acid (UA), fasting blood glucose (FBG), total cholesterol (TC), triglycerides (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL), increases in the NC, NLR, and PLR and a decrease in the LC were shown to be independent risk factors for ED. Receiver operating characteristic (ROC) curve analysis showed that the NLR exhibited better diagnostic performance for ED than the other parameters.

CONCLUSION

Increases in the NC, NLR, and PLR and a decrease in the LC significantly increased the risk of ED. The NC, LC, NLR and PLR could contribute to the diagnosis and assessment of ED. Zhangcheng L, Yuxin T, Xiucheng L and Dongjie L, et al. The Relationship Between Hematologic Parameters and Erectile Dysfunction. Sex Med 2021;9:100401.

Sexual Dysfunction and the Impact of Beta-Blockers in Young Males With Coronary Artery Disease

Objective: We aimed to assess the association of erectile dysfunction (ED) with the extent of coronary atherosclerosis, and to examine whether revascularization and medication use have an impact on ED status in patients with early onset of coronary artery disease (EOCAD).

Methods: International Index of Erectile Function (IIEF-5) was used to evaluate sexual function in 296 male patients with EOCAD (age, 39.9 ± 4.8 years), and 354 male controls (age, 40.6 ± 4.4 years). The extent of coronary atherosclerosis was measured by Gensini score. Endothelial function was evaluated by two vasomotor indexes including endothelin-1 (ET-1) and nitric oxide (NO) by ELISA.

Results: ED was more frequent (57.8 vs. 31.1%, P < 0.001) and serious (IIEF-5 score:17.7 ± 6.0 vs. 21.6 ± 5.0, P < 0.001) among EOCAD patients than that among controls. IIEF-5 score was negatively correlated with Gensini score (r = −0.383, P < 0.001). The adjusted odds ratio (OR) for the presence of ED (EOCAD vs. controls) was 1.88 [95% confidential interval (CI), 1.12-3.18]. However, ET-1 and NO attenuated the association between ED and EOCAD (adjusted OR: 1.54, 95% CI: 0.84-2.80). IIEF-5 score increased after coronary revascularization in patients not on beta-blockers (18.71 ± 4.84 vs. 17.59 ± 6.05, P < 0.001) as compared with baseline, while stayed unchanged in the subgroup using beta-blockers (17.82 ± 5.12 vs. 17.70 ± 5.98, P = 0.09).

Conclusions: ED was common in patients with EOCAD, and associated with the severity of coronary atherosclerosis. Endothelial dysfunction may be a pathophysiologic mechanism underlying both ED and EOCAD. Coronary revascularization confers a benefit in ED amelioration, while this effect did not appear in patients using beta-blocker.

Erectile Dysfunction as a Cardiovascular Risk Factor: Time to Step Up?

BACKGROUND

Erectile dysfunction (ED) is a major health problem that affects a significant proportion of the general population, and its prevalence is even higher in patients with CV risk factors and/or disease. ED and cardiovascular (CV) disease share several common pathophysiological mechanisms, and thus, the potential role of ED as a predictor of CV events has emerged as a significant research aspect.

OBJECTIVE

The purpose of this review is to present and critically discuss data assessing the relation between ED and CV disease and the potential predictive value of ED for CV events.

METHODS

A comprehensive review of the literature has been performed to identify studies evaluating the association between ED and CV disease.

RESULTS

Several cross-sectional and prospective studies have examined the association between ED and CV disease and found an increased prevalence of ED in patients with CV disease. ED was shown to independently predict future CV events. Importantly, ED was found to precede the development of overt coronary artery disease (CAD) by 3 to 5 years, offering a "time window" to properly manage these patients before the clinical manifestation of CAD. Phosphodiesterase type 5 inhibitors are the first-line treatment option for ED and were shown to be safe in terms of CV events in patients with and without CV disease.

CONCLUSION

Accumulating evidence supports a strong predictive role of ED for CV events. Early identification of ED could allow for the optimal management of these patients to reduce the risk for a CV event to occur.

Update of the position paper on arterial hypertension and erectile dysfunction

: Sexual health is an integral part of overall health, and an active and healthy sexual life is an essential aspect of a good life quality. Cardiovascular disease and sexual health share common risk factors (arterial hypertension, diabetes mellitus, dyslipidemia, obesity, and smoking) and common mediating mechanisms (endothelial dysfunction, subclinical inflammation, and atherosclerosis). This generated a shift of thinking about the pathophysiology and subsequently the management of sexual dysfunction. The introduction of phosphodiesterase type 5 inhibitors revolutionized the management of sexual dysfunction in men. This article will focus on erectile dysfunction and its association with arterial hypertension. This update of the position paper was created by the Working Group on Sexual Dysfunction and Arterial Hypertension of the European Society of Hypertension. This working group has been very active during the last years in promoting the familiarization of hypertension specialists and related physicians with erectile dysfunction, through numerous lectures in national and international meetings, a position paper, newsletters, guidelines, and a book specifically addressing erectile dysfunction in hypertensive patients. It was noted that erectile dysfunction precedes the development of coronary artery disease. The artery size hypothesis has been proposed as a potential explanation for this observation. This hypothesis seeks to explain the differing manifestation of the same vascular condition, based on the size of the vessels. Clinical presentations of the atherosclerotic and/or endothelium disease in the penile arteries might precede the corresponding manifestations from larger arteries. Treated hypertensive patients are more likely to have sexual dysfunction compared with untreated ones, suggesting a detrimental role of antihypertensive treatment on erectile function. The occurrence of erectile dysfunction seems to be related to undesirable effects of antihypertensive drugs on the penile tissue. Available information points toward divergent effects of antihypertensive drugs on erectile function, with diuretics and beta-blockers possessing the worst profile and angiotensin receptor blockers and nebivolol the best profile.

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.

Comparison of efficacy and safety of daily oral L-arginine and PDE5Is alone or combination in treating erectile dysfunction: A systematic review and meta-analysis of randomised controlled trials

The meta-analysis was performed to assess the efficacy and safety of daily oral L-arginine and phosphodiesterase type 5 inhibitors (PDE5Is) alone or combination in treating patients with erectile dysfunction (ED). We performed a search of randomised controlled trials in the following databases: PubMed, EMBASE and Cochrane Library databases. Four articles including 373 patients were studied. Erectile functions were significantly improved in three therapy groups compared with baseline. Patients who received the combination of L-arginine and PDE5Is showed significant improvement compared to those treated with L-arginine and PDE5Is alone, as assessed by sexual function index (p <0.00001 and p =0.005, respectively) and total testosterone (p <0.00001 and p =0.0007, respectively). Furthermore, patients who treated with PDE5Is alone exhibited the better efficacy than those treated with L-arginine alone in respects of sexual function index (p <0.00001) and total testosterone (p =0.0001). However, the combination of L-arginine and PDE5Is had no obvious difference relative to PDE5Is alone in terms of various adverse events (AEs). Conclusively, compared with monotherapy, the combination of L-arginine and PDE5Is showed a greater improvement of sexual function and total testosterone, and did not significantly increase the AEs. Besides, PDE5Is alone revealed a better effect than those treated with L-arginine alone for patients with ED.

Novel predictive risk factor of erectile dysfunction: Serum 25-hydroxy vitamin D

The present study aimed to investigate the association between the severity of erectile dysfunction (ED) and serum 25-hydroxy vitamin D. It also sought to determine the cut-off level of serum 25-hydroxy vitamin D for ED. This study included 130 men who had ED between 2018 and 2019. Patients were divided into three groups according to their scores on the international index of erectile function-5 (IIEF-5) Turkish validated short form questionnaire. The serum 25-hydroxy vitamin D results were compared between the groups. The mean age of the patients was 49.28 ± 13.62 years. Groups 1, 2 and 3 included 44 (33.8%) patients with severe ED, 56 (43.1%) patients with moderate ED and 30 (23.1%) patients with mild ED, respectively. Statistical significance was observed between the groups and serum 25-hydroxy vitamin D levels. A positive correlation was detected between the IIEF-5 scores, serum testosterone and serum 25-hydroxy vitamin D levels. A cut-off level for serum 25-hydroxy vitamin D was calculated as 27.32 ng/ml. During multivariate analysis, we found that serum 25-hydroxy vitamin D levels were independent prognostic risk factors for decreased IIEF-5 scores. Decreased serum 25-hydroxy vitamin D levels were associated with decreased IIEF-5 scores. Therefore, vitamin D replacement therapy may improve symptoms.

Is the History of Erectile Dysfunction a Reliable Risk Factor for New Onset Acute Myocardial Infarction? A Systematic Review and Meta-Analysis

Acute myocardial infarction (AMI) occurs as a manifestation of coronary atherosclerotic disease. The occurrence of erectile dysfunction (ED) following AMI is well documented and this association and pathophysiology is often interrelated. Few studies have objectively assessed the diagnostic value of ED as a risk factor for AMI, in general. In this review, we aimed to better outline the diagnostic predictability of ED as a precursor for 'first/new onset' AMI. This review was performed using selective search terms, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The Cochrane, Embase, PubMed, Scopus and Web of Science databases were searched (September 2018). Selected studies were further assessed for relevance and quality (Critical Appraisal Skills Program tool-Oxford). Four studies [573 participants; mean 143 (SD ± 76.3604) and median 141 participants] were eligible for analysis. Meta-analysis of the studies resulted in a pooled sensitivity of 51.36% (95% CI: 47.37-55.33%). For the single study which reported true negative and false positive cases, a specificity of 76.53% (95% CI: 68.57-83.00%) was calculated. The results of this systematic review and meta-analysis suggest that a history of ED should be used as a risk factor for new onset AMI.

Survival of Patients on Hemodialysis with Erectile Dysfunction

Background and objectives: In patients on hemodialysis, erectile dysfunction is an independent mortality factor. This study aimed to determine the risk factors that affect the survival of hemodialysis patients with erectile dysfunction. Materials and Methods: During a seven-year period, erectile dysfunction was identified among the fatalities reported in patients receiving chronic hemodialysis, on the basis of the International Index of Erectile Function questionnaire. The study covered 70 patients of mean age 57 ± 6.7 years. During the examined period, 42 (60%) patients died at the mean age 57 ± 6.8 years. The study was completed by 28 (40%) patients, aged 57 ± 6.55 years. Laboratory, demographic, anthropometric, and clinical characteristics were recorded using standard methods. Results: Statistically significant differences between the two groups of respondents were found concerning dialysis duration (p < 0.001), number of leukocytes (p = 0.003), adequacy of hemodialysis (p = 0.004), intima media thickness of the carotid artery (p < 0.001), presence of cardiovascular disease (p = 0.03), residual diuresis (p = 0.04), and hemodiafiltration (p < 0.001). Hemodialysis adequacy (B = -9.634; p = 0.017), intima media thickness (B = 0.022; p = 0.003), residual diuresis (B = -0.060; p = 0.007), and lower rates of cardiovascular disease (B = 0.176; p = 0.034) were significant survival predictors among our patients with erectile dysfunction. Conclusions: Risk factors that are associated with improved survival of patients on hemodialysis with erectile dysfunction in our study are: preserved diuresis, high-quality hemodialysis, lower incidence of cardiovascular disease, and less thickening of the intima media of the carotid arteries.

Epidemiology and Diagnosis of Erectile Dysfunction by Urologists Versus Non-Urologists in the United States: An Analysis of the National Ambulatory Medical Care Survey

OBJECTIVES

To evaluate the extent to which erectile dysfunction (ED) is managed by urologists versus non-urologists. We sought to characterize the epidemiology, diagnosis, and outpatient treatment of ED using a nationally representative cohort.

METHODS

We examined all male patient visits between 2006 and 2016 in the National Ambulatory Medical Care Survey, a survey designed to provide a nationally representative estimate of ambulatory visits in the United States. Distribution of ED diagnoses among physician specialties was determined. Demographic, clinical, and treatment characteristics of men with ED seeing urologists versus non-urologists were compared using chi-squared tests.

RESULTS

Among the 170,499 patient visits analyzed, 1.2% were associated with a diagnosis of ED, which translated into 3,409,244 weighted visits annually. Visits for ED were predominantly seen by urologists (58.0%) and family practitioners (26.2%). Men visiting non-urologists for ED were more likely to be younger than 65 (77.4% vs 52.9%, P < .05). Men seeing urologists for ED more frequently had an active cancer diagnosis (24.2% vs 2.8%, P < .05). Non-urologists more readily ordered or reordered phosphodiesterase-5 inhibitors for men with ED (66.62% vs 50.77%, P < .05). Advanced therapies such as intracavernosal injections and intra-urethral agents were almost exclusively ordered by urologists compared to non-urologists (2.72% vs 0.25%, P < .05).

CONCLUSION

Almost half of all ED visits were seen by non-urologist providers, who were much less likely than urologists to order advanced pharmacologic therapies. This difference in prescribing patterns presents an opportunity for interdisciplinary collaboration and education to ensure that all patients seeking treatment for ED are receiving guideline-based care.

Erectile Dysfunction After Surgical Treatment of Lung Cancer: Real-World Evidence

Background

Sexual problems are common in male lung cancer survivors. However, the development of erectile dysfunction (ED) in lung cancer patients after surgery has been rarely explored. In this study, we aimed to explore the incidence and risk factors of ED after lung cancer surgery.

Methods

From 2000 to 2012, 6025 and 24,100 male patients were included in each matched cohort of lung cancer and non-lung cancer patients, respectively. Poisson regression analysis was used to calculate the incidence rate ratio (IRR) and 95% confidence interval (CI).

Results

The incidence of ED was higher in the lung cancer cohort compared to the non-lung cancer cohort (38.47 vs 28.28 per 10,000 person-years) with an adjusted IRR (aIRR) of 1.34 (95% CI: 1.06-1.70, p=0.014) after the confounders were adjusted for. An increased incidence of ED was observed in the lung cancer cohort aged 40-54 years (aIRR: 5.44, 95% CI: 2.25-13.15, p<0.001), 55-64 years (aIRR: 3.62, 95% CI: 1.61-8.17, p=0.002) years, and anxiety (aIRR: 2.99, 95% CI: 1.81-4.94, p<0.001). In addition, a higher incidence of emergency room (ER) visits (aIRR: 2.19, 95% CI: 1.98-2.42, p<0.001) was observed in lung cancer patients with ED compared to those without ED.

Conclusion

Our study results suggested that early surveillance and intervention of ED should be advocated in lung cancer patients after surgery.

The relationship between erectile dysfunction severity, mean platelet volume and vitamin D levels

Background: The aim of this study was to evaluate the relationship between mean platelet volume (MPV) and vitamin D levels according to ED severity.Methods: Between October 2015 and September 2017, patients who applied to the andrology outpatient clinic with an ED complaint were retrospectively reviewed. Patients with diabetes, hypertension, hyperlipidemia, malignancy, late-onset hypogonadism and smokers were not included in the study. The International Erectile Function Index-Erectile Function (IIEF-EF) questionnaire was used to assess the levels of erectile function. According to this scoring system, patients were divided into two groups. IIEF score: between 17 and 25 = mild ED (Group 1) and IIEF score between 16 and 0 = moderate-severe ED (Group 2). Blood samples of the patients were taken from antecubital vein and MPV and 25-hydroxyvitamin D [25(OH)D] levels were evaluated.Results: Ninety patients were included in the study (Group 1: n = 41, Group 2: n = 49). The mean age of the patients was 41.07 ± 8.56 and the mean body mass index (BMI) was 27.59 ± 3.91. 25(OH)D levels were found to be statistically lower in Group 2 (18.85 ± 6.09; 13.98 ± 7.10; p = .001). MPV levels were found to be statistically higher in Group 2 (10.05 ± 0.81; 10.78 ± 1.16; p = .001). Correlation between IIEF-EF scores and 25(OH)D levels was positive (p = .03, r = 0.22). There was negative correlation between IIEF-EF scores and MPV and between 25(OH)D levels and MPV levels [p = .003 for IIEF-EF/MPV, p = .04, r = -0.23 for 25(OH)D/MPV].Conclusion: There is a significant positive correlation between ED severity and 25(OH)D levels and there is a significant negative correlation between ED severity and MPV levels.

An enhanced prognostic score for overall survival of patients with cancer derived from a large real-world cohort

BACKGROUND

By understanding prognostic biomarkers, we gain insights into disease biology and may improve design, conduct, and data analysis of clinical trials and real-world data. In this context, we used the Flatiron Health Electronic Health Record-derived deidentified database that provides treatment outcome and biomarker data from >280 oncology centers in the USA, organized into 17 cohorts defined by cancer type.

PATIENTS AND METHODS

In 122 694 patients, we analyzed demographic, clinical, routine hematology, and blood chemistry parameters within a Cox proportional hazard framework to derive a multivariable prognostic risk model for overall survival (OS), the 'Real wOrld PROgnostic score (ROPRO)'. We validated ROPRO in two independent phase I and III clinical studies.

RESULTS

A total of 27 variables contributed independently and homogeneously across cancer indications to OS. In the largest cohort (advanced non-small-cell lung cancer), for example, patients with elevated ROPRO scores (upper 10%) had a 7.91-fold (95% confidence interval 7.45-8.39) increased death hazard compared with patients with low scores (lower 10%). Median survival was 23.9 months (23.3-24.5) in the lowest ROPRO quartile Q1, 14.8 months (14.4-15.2) in Q2, 9.4 months (9.1-9.7) in Q3, and 4.7 months (4.6-4.8) in Q4. The ROPRO model performance indicators [C-index = 0.747 (standard error 0.001), 3-month area under the curve (AUC) = 0.822 (0.819-0.825)] strongly outperformed those of the Royal Marsden Hospital Score [C-index = 0.54 (standard error 0.0005), 3-month AUC = 0.579 (0.577-0.581)]. We confirmed the high prognostic relevance of ROPRO in clinical Phase 1 and III trials.

CONCLUSIONS

The ROPRO provides improved prognostic power for OS. In oncology clinical development, it has great potential for applications in patient stratification, patient enrichment strategies, data interpretation, and early decision-making in clinical studies.

Perception of the association between erectile dysfunction and cardiovascular disease among Chinese physicians: an online survey

Objective

There is a close association between erectile dysfunction (ED) and cardiovascular disease (CVD). This study aimed to investigate Chinese physicians’ understanding of this association.

Methods

A total of 651 physicians, including 245 cardiologists and 406 urologists, participated in our investigation through WeChat.

Results

Participants with more professional experience, a doctoral/postdoctoral degree, and an intermediate/senior title were significantly more likely to be aware of a close association between ED and CVD. Urologists had a significantly better understanding of the association of severity between both diseases, showed more positive attitudes towards phosphodiesterase type 5 inhibitor application in patients with CVD and systematic treatment, and gave greater consideration to both diseases during follow-up visits than did cardiologists. Men had a significantly better understanding of the associated severity of the two disorders and managed the two diseases together more actively than did women. Department, sex, professional experience, education, and affiliated hospital level significantly affected systematic management of ED and CVD.

Conclusion

Most physicians from cardiology and urology are aware of the association between ED and CVD, but this awareness may be insufficient. Department, sex, professional experience, education background, and professional title are significant factors associated with perception of this association.

Lifestyles and sexuality in men and women: the gender perspective in sexual medicine

Sexual health is strictly related with general health in both genders. In presence of a sexual dysfunction, the expert in sexual medicine aims to discover the specific weight of the physical and psychological factors can cause or con-cause the sexual problem. At the same time, a sexual dysfunction can represent a marker of the future development of a Non-communicable diseases (NCDss) as cardiovascular or metabolic diseases.In the evaluation phase, the sexual health specialist must focus on these aspects, focusing especially on the risk and protective factors that could impact on both male and female sexuality.This article presents a review of researches concerning healthy and unhealthy lifestyles and their contribute in the development of sexual quality of life in a gender-dependent manner.Among the unhealthy lifestyle, obesity contributes mostly to the development of sexual dysfunctions, due to its negative impact on cardiovascular and metabolic function. Tobacco smoking, alcohol - substance abuse and chronic stress lead to the development of sexual dysfunction in a med-long term.In order to guarantee a satisfying sexual quality of life, sexual health specialists have the responsibility to guide the patient through the adoption of healthy lifestyles, such as avoiding drugs, smoke and excessive alcohol, practicing a regular physical activity, following a balanced diet and use stress-management strategies, even before proposing both pharmaco- and/or psychotherapies.

Prevalence of Asymptomatic Coronary Artery Stenosis Based on Coronary Computed Tomography Angiography in Adults with Erectile Dysfunction: A Cross-Sectional Study

OBJECTIVES

To investigate the prevalence of asymptomatic coronary artery stenosis (CAS) using coronary computed tomography angiography (CCTA) in Korean men with erectile dysfunction (ED).

SUBJECTS AND METHODS

A cross-sectional study was conducted on 108 men who underwent CCTA at a health promotion center in Pusan National University Yangsan Hospital. Each subject who was evaluated for ED using the International Index of Erectile Dysfunction (IIEF) questionnaire did not have a past history or symptoms of coronary artery disease (CAD). We assessed the association between ED and CCTA-based CAS.

RESULTS

The overall prevalence of ED was 57.4%; furthermore, age (p = 0.001) and fasting blood glucose (p =0.035) were the metabolic risk factors that were most significantly associated with the presence of ED. The overall frequency of CAS was 31.5%, and ED (p = 0.022), age (p < 0.001), fasting blood glucose (p = 0.021), and total cholesterol/high-density lipoprotein cholesterol (p = 0.029) were significantly associated with the presence of CAS. The prevalence of CAS was 40.3 and 19.6% in the ED and non-ED groups, respectively. Men with ED were 2.778 times more likely to present with CAS than those without ED (OR 2.778, 95% CI 1.143-6.749, p = 0.024); however multivariate logistic regression analysis, while controlling for age, total cholesterol/high-density lipoprotein cholesterol, and fasting blood glucose, suggested the absence of a significant association between ED and CCTA-based CAS.

CONCLUSION

This study shows that CCTA-based CAS is a common phenomenon in men who have ED. Furthermore, ED patients without cardiac symptoms need to be investigated for the possibility of hidden CAD.

Update on cardiovascular prevention in clinical practice: A position paper of the European Association of Preventive Cardiology of the European Society of Cardiology

European guidelines on cardiovascular prevention in clinical practice were first published in 1994 and have been regularly updated, most recently in 2016, by the Sixth European Joint Task Force. Given the amount of new information that has become available since then, components from the task force and experts from the European Association of Preventive Cardiology of the European Society of Cardiology were invited to provide a summary and critical review of the most important new studies and evidence since the latest guidelines were published. The structure of the document follows that of the previous document and has six parts: Introduction (epidemiology and cost effectiveness); Cardiovascular risk; How to intervene at the population level; How to intervene at the individual level; Disease-specific interventions; and Settings: where to intervene? In fact, in keeping with the guidelines, greater emphasis has been put on a population-based approach and on disease-specific interventions, avoiding re-interpretation of information already and previously considered. Finally, the presence of several gaps in the knowledge is highlighted.

The global prevalence of erectile dysfunction: a review

OBJECTIVE

To evaluate the global prevalence of erectile dysfunction (ED); as well as its association with physiological and pathological ageing by examining the relationship between ED and cardiovascular disease (CVD), benign prostatic hyperplasia (BPH), and dementia. We also aimed to characterise discrepancies caused by the use of different ED screening tools.

METHODS

The Excerpta Medica dataBASE (EMBASE) and Medical Literature Analysis and Retrieval System Online (MEDLINE) were searched to find population-based studies investigating the prevalence of ED and the association between ED and CVD, BPH, and dementia in the general population.

RESULTS

The global prevalence of ED was 3-76.5%. ED was associated with increasing age. Use of the International Index of Erectile Function (IIEF) and Massachusetts Male Aging Study (MMAS)-derived questionnaire identified a high prevalence of ED in young men. ED was positively associated with CVD. Men with ED have an increased risk of all-cause mortality odds ratio (OR) 1.26 (95% confidence interval [CI] 1.01-1.57), as well as CVD mortality OR 1.43 (95% CI 1.00-2.05). Men with ED are 1.33-6.24-times more likely to have BPH then men without ED, and 1.68-times more likely to develop dementia than men without ED.

CONCLUSION

ED screening tools in population-based studies are a major source of discrepancy. Non-validated questionnaires may be less sensitive than the IIEF and MMAS-derived questionnaire. ED constitutes a large burden on society given its high prevalence and impact on quality of life, and is also a risk factor for CVD, dementia, and all-cause mortality.