© The Canadian Journal of Urology™; 21(3); June Supplement 2014
Address correspondence to Dr. Martin Miner, The Men’s
Health Center, The Miriam Hospital, 164 Summit Avenue,
Providence, RI 02906 USA
Erectile dysfunction in primary care: a focus
on cardiometabolic risk evaluation and
stratification for future cardiovascular events
Martin Miner, MD,
1
Matt T. Rosenberg, MD,
2
Jack Barkin, MD
3
1
Departments of Family Medicine and Urology, Miriam Hospital, Brown University, Providence, Rhode Island, USA
2
Mid Michigan Health Centers, Jackson, Michigan, USA
3
Department of Surgery, University of Toronto, Humber River Regional Hospital, Toronto, Ontario, Canada
MINER M, ROSENBERG MT, BARKIN J. Erectile
dysfunction inprimarycare: a focusoncardiometabolic
risk evaluation and stratification for future
cardiovascular events.
Can JUrol
2014;21(Suppl 2):25-38.
An association between erectile dysfunction (ED) and
cardiovascular disease has long been recognized, and
studies suggest that ED is an independent marker of
cardiovascular disease risk and even further, a marker
for the burden of both obstructive and non-obstructive
coronary artery disease. Therefore, the primary care
physician (PCP) must assess the presence or absence of
ED in every man > 39 years of age, especially if that man
is asymptomatic of signs and symptoms of coronary artery
disease. Assessment and management of ED may help
identify and reduce the risk of future cardiovascular events,
particularly in younger middle-aged men. The initial ED
evaluation should distinguish between predominantly
vasculogenic ED and ED of other etiologies. For men
believed to have predominantly vasculogenic ED, we
recommend that initial cardiovascular risk stratification
be based on the Framingham Risk Score. Management
of men with ED who are at low risk for cardiovascular
disease should focus on risk factor control; men at high
risk, including those with cardiovascular symptoms,
should be referred to a cardiologist. Intermediate risk men
should undergo noninvasive evaluation for subclinical
atherosclerosis. A growing body of evidence supports the
use of selected prognostic markers to further understand
cardiovascular risk in men with ED, particularly CT
calcium scoring. In conclusion, we support cardiovascular
risk stratification and risk factor management in all men
with vasculogenic ED.
Key Words:
erectile dysfunction, cardiovascular,
primary care
Sexual function is a complex, multifactorial
process. The implementation of sexual inquiry in
primary care should occur at a minimum during the
health surveillance visit or during the initiation of
another therapy that might affect sexual function (e.g.
hypertensionmanagement). The development of ED is
attributable to both psychogenic factors andphysiologic
alterations in neural, vascular, hormonal andmetabolic
perturbations, all mediated through endothelial and
smooth muscle dysfunction. The fact that ED often
coexists with hypertension, hyperlipidemia, and
diabetes
2
provides support for a vasculogenic etiology
of ED. Beyond its associationwith vascular risk factors,
vasculogenic ED has been recently recognized as a
marker of both early endothelial and smooth muscle
dysfunction and the first of many factors influencing
the cascade of future cardiovascular (CVS) events.
Consequently, the identification of largely organic ED
through history-taking and sexual inquiry and the
subsequent work up and potential identification of
“plaque burden” in the youngermiddle-agedman have
significant prognostic import.
Introduction
Erectile dysfunction (ED), defined as the inability
to maintain and achieve an erection sufficient for
satisfactory intercourse, has a high prevalence
and incidence worldwide.
1
A systematic review of
epidemiologic evidence undertaken in 2002 showed
a clear increase in prevalence in with advancing age,
with rates for men younger than 40 years ranging from
approximately from 2%-9%, compared with 18%-86%
for those older than 80 years.
2
Although not life-
threatening, it may be a precursor or marker of more
serious conditions, particularly coronary artery disease
(CAD). Inman et al
3
have shown when ED occurs in
younger men, particularly less than 50 years old, it is
associated with a marked increase in the risk of future
cardiac events. Overall EDmay be associated with an
approximately 80% higher risk of subsequent CAD.
3
25
