Erectile Dysfunction as an Early Sign of Cardiovascular Disease

24.01.2024 - Ori Gidor | Medically reviewed by Prof. Cobi Reisman MD, PhD, FECSM, ECPS

For some men, erectile dysfunction might be a warning sign of an underlying or future cardiovascular disease. How are these two conditions linked? Keep reading to learn more.

Erectile dysfunction (ED) – the most common sexual problem in men, is defined as the continuous inability to obtain and maintain an erection firm enough for satisfactory sexual intercourse. ED affects up to 350 million men worldwide, and it is known that the risk of developing this condition increases with age.

ED might have certain negative psychological implications, and therefore it is unsurprising that men with ED may experience anxiety, low mood, and low self-esteem. However, ED may as well affect a man’s physical health, and studies show it may indicate the existence of vascular diseases, an underlying heart disease, or otherwise, one which is currently developing.

Cardiovascular diseases (CVD) are considered the leading cause of mortality globally, [1] and 60% of these deaths are associated with atherosclerotic CVD, which involves the narrowing of arteries due to plaque buildup in their inner lining. When a plaque becomes very advanced, it can block the artery entirely. Examples of atherosclerotic CVD include ischemic heart disease, ischemic stroke, and peripheral vascular disease[1,2].


Sharing Similar Risk Factors 

Erectile dysfunction and cardiovascular diseases are two medical conditions that share many risk factors, such as:

  • High cholesterol – high LDL cholesterol levels (“bad” cholesterol) might lead to atherosclerosis, narrowed arteries, and reduced blood flow to both the heart and the penis.
  • Diabetes– diabetic men are at high risk of developing erectile dysfunction and heart disease.
  • High blood pressure– over time, hypertension damages the lining of the arteries (the endothelial layer), which accelerates the process of vascular disease. Additionally, certain hypertension medications may cause erectile dysfunction.
  • Obesity– excess weight, particularly belly fat accumulation (visceral fat), worsens other risk factors for heart disease.
  • Low testosterone –among men with low testosterone, there are higher rates of erectile dysfunction and cardiovascular disease than men with normal testosterone levels.
  • Age– as men age, their risk of developing erectile dysfunction increases. However, the younger a man is, the more likely it is that erectile dysfunction indicates a risk of heart disease.
  • Smoking – tobacco use increases the risk of developing vascular disease, which can result in erectile dysfunction.
  • Alcohol use– high alcohol consumption can lead to heart disease and might contribute to other causes of heart disease, such as hypertension or high cholesterol levels. Drinking alcohol before sexual activity might also impair erections.

However, although numerous studies have indicated that men with ED are at greater risk of developing cardiovascular disease, the association between ED as an early sign of CVD has been unclear.


Erectile Dysfunction and Silent Heart Disease

In an important study from 2017, the researchers found a link between ED and sub-clinical cardiovascular diseases. The term “sub-clinical” refers to “silent” diseases – before symptoms become apparent when a person does not feel pain or other symptoms and is unaware of the disease. In the study, the researchers analyzed the results of 28 clinical studies and identified a strong association between ED and dysfunction of the endothelial layer that lines the arteries. Endothelial dysfunction is a condition in which blood vessels cannot properly dilate to allow adequate blood flow through them. It is an early sign of atherosclerosis – a condition that raises the risk of heart attacks, strokes, and ED due to plaque buildup in the arteries. 

Moreover, the researchers found that ED was associated with an increased thickness of the intima-media layer in the carotid arteries that supply the heart – an early marker of carotid atherosclerosis.

One of the recent studies examined the link between ED and severe cardiovascular events, such as heart attacks, stroke, and death due to cardiac events. The results showed that out of the 1,757 men included in the study (ages 60-78), those who reported ED at the onset were twice as likely to have a heart attack or other cardiac event during the 3.8-year study period. The researchers concluded that ED constitutes an independent predictor of future CVD and suggested that physicians should screen patients reporting ED symptoms, even in the absence of any cardiovascular symptoms at present.

Additional studies in this field have yielded similar results. In one study, men with ED but no other clinical symptoms of CVD were found to have reduced vasodilation in the brachial artery (the artery that crosses the arm) in response to vasodilating medication. These results indicated endothelial dysfunction of the brachial artery and reduced blood flow [3]. A different study of men with ED of vascular origin showed that 19% had silent coronary artery disease, as was documented by an angiography [4]. It has been likewise discovered that men with moderate-severe ED had a 65% increased risk of developing coronary artery disease within 10 years compared to men without ED [5].


The Bottom Line

Although the occurrence of ED does not always reflect the existence of underlying heart disease, the literature clearly supports the link between ED and CVD. Study results consistently demonstrate that ED, as a sign of penile endothelial dysfunction, usually reflects an existing sub-clinical (silent) heart disease [6]. Furthermore, ED and CVD constitute, in essence, different manifestations of systemic arterial damage. The reason ED occurs earlier than ischemic heart disease, for example, relates to the smaller diameter of penile arteries (compared to coronary arteries) and their tendency to clog faster [7]. Accordingly, it is estimated that ED precedes the first cardiovascular event by three years on average [8].

Since over 50% of men do not have warning signs of coronary artery disease prior to their first cardiovascular event [9], ED could be an essential marker for the presence of silent vascular disease in asymptomatic men.

According to the researchers, all these findings are particularly important for younger men, who may be visiting the doctor for the first time due to ED, and who are less likely to be assessed for sub-clinical CVD than older men, without any additional symptoms. However, study results indicate that such men are at greater risk and will benefit from a full CVD risk assessment.


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