Erectile dysfunction strong predictor of death, cardiovascular outcomes

In the first study to show that ED is predictive of death and cardiovascular outcomes, researchers found that men with CVD and ED (compared to those without ED) were twice as likely to suffer death from all causes and 1.6 times more likely to suffer the composite of cardiovascular death, heart attack, stroke and heart failure hospitalization. More specifically, they were:

• 1.9 times more likely to die from cardiovascular disease;
• twice as likely to have a heart attack;
• 1.2 times more likely to be hospitalized for heart failure; and
• 1.1 times more likely to have a stroke.

The researchers also found that, though ACE inhibitors, angiotensin receptor blockers or a combination of the two, can reduce cardiovascular events in high-risk patients, the medications didn't influence the course nor the development of ED.

"Erectile dysfunction is something that regularly should be addressed in the medical history of patients; it might be a symptom of early atherosclerosis," said Michael Böhm, M.D., lead author of the study and chairman of internal medicine in the Department of Cardiology and Intensive Care at the University of Saarland, Germany.

The worldwide study included 1,519 men from 13 countries in a substudy of the ONTARGET and TRANSCEND trials of cardiovascular patients. The men answered a questionnaire to determine whether they had ED. Men with ED were then categorized as having mild, mild-to-moderate, moderate or severe ED. The questionnaires were given at the initial visit, after two years or at the final visit after an average follow-up of five years.

ONTARGET patients were either randomly assigned to the ACE inhibitor drug ramipril (400 patients), telmisartan (395 patients) or a combination (381 patients). In TRANSCEND, researchers randomized ACE inhibitor-intolerant patients to placebo (202 patients) or telmisartan (171 patients).

The researchers found that patients with ED were older, and had a higher prevalence of hypertension, stroke, diabetes and lower urinary tract surgery than those without ED. Furthermore, 55 percent of the men had ED at entry in the trials.

Deaths from all causes occurred in 11.3 percent of the patients who reported ED at baseline, but in only 5.6 percent of those with no or mild ED at the start of the study. The composite primary outcome of cardiovascular death, heart attack, stroke and heart failure hospitalization occurred in 16.2 percent of ED patients compared to 10.3 percent of patients with no or mild ED.

The risks of death from all causes and composite outcome increased in a stepwise manner with the progression of ED, researchers said.

"It is likely that the presence of ED identified individuals whose cardiovascular disease might be far more advanced than when evaluated with other clinical parameters alone," Böhm said.

ED is closely associated with the endothelial dysfunction that occurs in atherosclerosis and the vascular disturbances such as the build-up of plaque that precedes events such as heart attack and stroke, Böhm said.

"Men with ED going to a general practitioner or a urologist need to be referred for a cardiology workup to determine existing cardiovascular disease and proper treatment," Böhm said. "ED is an early predictor of cardiovascular disease."

Many men with ED see a general practitioner or a urologist to get medication for ED, he said.

"The medication works and the patient doesn't show up anymore," Böhm said. "These men are being treated for the ED, but not the underlying cardiovascular disease. A whole segment of men is being placed at risk."

Men need to consider ED as a risk factor for cardiovascular disease just as high blood pressure and cholesterol are, Böhm said. "If a man has erectile dysfunction, then he needs to ask his physician to check for other risk factors of cardiovascular disease."

Co-authors are: Magnus Baumhakel, M.D.; Koon Teo, M.B., Ph.D.; Peter Sleight, M.D.; Jeffrey Probstfield, M.D.; Peggy Gao, M.Sc.; Johannes F. Mann, M.D.; Rafael Diaz, M.D.; Gilles R. Dagenais, M.D.; Garry L.R. Jennings, M.D.; Lisheng Liu, M.D.; Petr Jansky, M.D. and Salim Yusuf, M.B., B.S. Author disclosures are on the manuscript.

Boehringer-Ingelheim, Germany funded the substudy.