Erectile dysfunction and heart attack

“Men who suffer impotence are being given an early warning sign that a heart attack is on the way,” the Daily Express reported. Men with the condition, which can be a sign of a hardening of the arteries, are 50% more likely to have a heart attack. It can serve as a warning sign to doctors up to three years before an event. It said that a urology consultant, Dr Geoffrey Hackett, had “blasted” fellow medics in a letter to the BMJ for not identifying impotence as a way of spotting those at risk. The newspaper said impotence is particularly good at showing heart attack risk in men with diabetes, and was more accurate at predicting heart attacks than high blood pressure or high cholesterol.

This is an area that requires consideration, but before proactive screening for erectile dysfunction becomes a standard part of cardiovascular risk assessment tools, the evidence will need to be reviewed to determine the benefits of adding this to existing screening tools. Meanwhile, men with erectile dysfunction should receive a thorough evaluation by their GP, who should be prompted to consider assessing other risk factors for cardiovascular disease.

Where did the story come from?

Dr Geoffrey Hackett, a consultant in urology from Good Hope Hospital in Birmingham wrote this letter to the British Medical Journal.

What kind of scientific study was this?

This was a letter written in response to another article in the journal written by Professor Rod Jackson and colleagues, which supported screening to identify individuals at high risk of cardiovascular events so that they can receive preventive treatment.

The letter expressed the author’s concern that screening for erectile dysfunction had not been specifically mentioned in this article. The author describes his personal experience in clinical practice and highlights some of the evidence regarding the relationship between erectile dysfunction and heart disease.

What were the results of the study?

The author says that he has seen patients with erectile dysfunction who have been referred to him after a coronary event, and who have reported that they had developed erectile dysfunction two to three years before their coronary event, but had been “dismissed” when they visited their GP.

The author goes on to say that erectile dysfunction is a “manifestation of vascular disease in smaller arteries, and gives a two to three-year early warning of myocardial infarction”, and that it increases the risk of coronary events by 50%. He provides references to published studies that have found a relationship between erectile dysfunction and risk of coronary events, and on which this figure of a 50% increase is based. This is a similar increase in risk as would be had from a moderate level of smoking, or of having a first-degree relative who has had a coronary event.

The author suggests that in people with type 2 diabetes, erectile dysfunction is a better predictor of the risk of a coronary event than other commonly used predictors such as glycated haemoglobin levels, high blood pressure, high levels of fats in the blood, or presence of albumin in the urine. He reports that over half of the men with type 2 diabetes have low testosterone levels, which increases risk of early cardiovascular death by 60%.

The author adds: “Despite this evidence we don’t even screen for erectile dysfunction or low testosterone in type 2 diabetes or patients with coronary heart disease. We prescribe drugs for coronary heart disease that make erectile dysfunction worse, even though there are drug treatments as effective which improve it, and then make the patients pay privately because we treat erectile dysfunction as a recreational or "lifestyle" issue.”

What interpretations did the researchers draw from these results?

The author concludes that “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”.

What does the NHS Knowledge Service make of this study?

This letter expresses the author’s opinion that erectile dysfunction should be used as a screening tool to identify those at high risk of having a coronary event. There are a number of methods currently used to identify those at high risk of cardiovascular events, that assess a variety of risk factors such as family history, smoking, levels of fats in the blood, blood pressure, and presence of other medical conditions such as diabetes.

To determine the benefits of adding proactive screening for erectile dysfunction to existing screening tools, a review of the evidence would be needed to determine whether it identifies substantially more people who can benefit from preventive treatment than those identified by existing tools (as many people will have a combination of these risk factors). As this appraisal has not analysed the supporting references listed by the author, it cannot confirm the reliability of the percentage risk estimates that were given (i.e. erectile dysfunction carrying an additional 50% risk of coronary events). Neither is it possible to substantiate the claims that “cardiologists feel uncomfortable mentioning the word erection to their patients” (the newspapers quote this as referring to GPs rather than cardiologists).

Erectile dysfunction has a wide variety of known medical causes, including cardiovascular disease, diabetes, hormonal disorders, neurological conditions, and drug-related problems. It can also have psychological causes, stemming from depression or relationship problems, for example. Men reporting erectile dysfunction to their GP should receive a thorough and full evaluation, and reporting of this symptom should prompt GPs to consider assessing other risk factors for cardiovascular disease in addition to exploring other potential causes.

Sir Muir Gray adds...

There’s no evidence yet that this should be added to the list of risk factors.