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The implications of erectile dysfunction

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Erectile dysfunction carries a 50 per cent additional risk of coronary events; a level comparable to moderate smoking or positive first-degree relative family history.

Although over 50 per cent of men over the age of 40 are thought to suffer with erectile dysfunction (ED), its role as a red flag for underlying conditions is still not fully understood, with both doctors and patients remaining unaware.

This was the view of Dr Geoff Hackett of the British Society for Sexual Medicine (BSSM), and consultant in sexual medicine, who wrote a scathing letter to the BMJ earlier this year lambasting a previous article that did not sufficiently explain the strong links between ED and cardiovascular disease.

Indeed, Dr Hackett wrote that the article “totally ignores the massive evidence base linking erectile dysfunction with cardiovascular risk”.

Citing the decreased life expectancy that men have compared with women, Dr Hackett said that doctors still see ED as a “recreational or lifestyle issue”.

He stated that it is known that ED and cardiovascular disease (CVD) share pathophysiological mechanisms and often co-occur. However, it is not known whether ED provides an early warning for increased CVD or other causes of mortality.

Dr Hackett cited a 2008 study published in the Journal of the American College of Cardiology that showed that the presence of ED predicts new onset of coronary heart disease (CHD) events in type 2 diabetic men without clinically overt CVD.

Dr Hackett spoke of how it has been shown that ED carries a 50 per cent additional risk of coronary events; a level comparable to moderate smoking or positive first-degree relative family history. He also stated that ED in type 2 diabetes is a better predictor of coronary risk than HbA1c, hypertension, microalbuminuria, or hyperlipidaemia, and he added that over 50 per cent of men with type 2 diabetes are hypogonadal, which carries a 60 per cent additional risk of early cardiovascular death.

Despite this evidence, ED or low testosterone is still not screened for in type 2 diabetes or patients with CHD, said Dr Hackett.

“Continuing to ignore these issues on the basis that cardiologists feel uncomfortable mentioning the word erection to their patients is no longer acceptable and probably clinically negligent,” he concluded.
Indeed, one of the most common concerns for healthcare professionals dealing with ED is simply mentioning it.

Some GPs feel the issue is taboo and research has shown that it can be especially difficult to discuss the subject with older men, as people still feel that sex in the elderly population is a sensitive subject.
Despite this, studies also show that patients appreciate being asked about sexual health problems and feel it is appropriate for healthcare professionals to do so.

Guidelines

Dr Hackett was instrumental in drawing up the BSSM guidelines for the management of ED.
“Despite the likely presence of such underlying conditions, many men with ED may undergo little or no evaluation before treatment, particularly if they seek help from sources such as the Internet.

The early diagnosis and management of such cardiovascular and endocrine conditions are fundamental to the GP’s role under the 2002 General Medical Services (GMS) contract. Men do not readily visit their GP with medical problems and a consultation for ED may represent an important opportunity for health intervention,” state the guidelines.

Mortality

A recent study sought to examine the association of ED with all-cause and cause-specific mortality.

A prospective population-based study of 1,709 men (of 3,258 eligible) aged 40 to 70 years was carried out. ED was measured by self-report and subjects were followed for a mean of 15 years. Hazard ratios (HR) were calculated using the Cox proportional hazards regression model.

The main outcome measures were mortality due to all causes, CVD, malignant neoplasms, and other causes.
It was found that of the 1,709 men, 1,284 survived to the end of 2004 and had complete ED and age data. Of 403 men who died, 371 had complete data.

After adjustment for age, body mass index (BMI), alcohol consumption, physical activity, cigarette smoking, self-assessed health, and self-reported heart disease, hypertension, and diabetes, ED was associated with HRs of 1.26 for all-cause mortality, and 1.43 for CVD mortality. The HR for CVD mortality associated with ED is of comparable magnitude to HRs of some conventional CVD risk factors.

According to the authors, these findings demonstrate that ED is significantly associated with increased all-cause mortality, primarily through its association with CVD mortality.

 

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