Silent CAD Common in Men with ED

Internal Medicine World Report, November 2007, Volume 0, Issue 0

New, Much Higher Incidence Rate

New, Much Higher Incidence Rate

By Wayne Kuznar

VIENNA, Austria—Routinely asking middle-aged men about their erectile function provides an opportunity to identify undiagnosed coronary artery disease (CAD), said Charalambos Vlachopoulos, MD, at the Congress of the European Society of Cardiology.

In his study, approximately 1 in 6 men with vasculogenic erectile dysfunction (ED) had documented asymptomatic CAD.

"ED is sometimes the first manifestation of a generalized disease before CAD has become clinically evident," he said. "Studies have shown that ED and CAD often coexist, as up to 75% of patients with CAD have some degree of ED."

Charalambos Vlachopoulos, MD

The incidence of asymptomatic CAD in 182 consecutive men (aged 38-77 years) with ED of vascular origin was assessed using coronary angiography. After providing a medical history, all the men initially underwent exercise treadmill testing and stress echocardiography imaging.

A total of 21% of the men had a positive exercise treadmill test, a positive stress echocardiogram, or both. Three patients suffered a myocardial infarction (MI) before they could complete the noninvasive investigation, said Dr Vlachopoulos, of the Department of Cardiology, Athens Medical School, Hippokration Hospital, Greece.

Cardiovascular risk factors were common in this group: 59% had hypertension, 53% were smokers, 51% had hyperlipidemia, 19% had diabetes, and 11% had a family history of premature vascular disease; 42 men (23%) had >2 risk factors.

Coronary angiography was performed in 33 of the men in whom the noninvasive testing was positive and in the 3 patients with acute MI. Five men who had positive noninvasive tests refused to undergo angiography.

Of 177 men, 25 (14%) had angiographically proven silent CAD; 6 had 3-vessel disease, 7 had 2-vessel disease, and 12 had single-vessel disease. Coronary artery ectasias was identified in 6 men.

The 14% rate of silent CAD in men with ED in this study is much greater than the 4% rate observed in a previous study of the general population, noted Dr Vlachopoulos.

Compared with men without CAD, those with CAD that was confirmed by angiography were older (58 vs 62 years), had a higher prevalence of diabetes, a longer duration of ED (24 vs 29 months), and greater impairment of erectile function, as estimated by mean peak systolic velocity of penile arteries on color Doppler ultrasonography (34.2 vs 27.5 cm/sec).

The absence of obstructive coronary lesions on angiography does not rule out the possibility of acute coronary events, because nonobstructive coronary plaques with a lipid-rich core and a thin fibrous cap are vulnerable to rupture, Dr Vlachopoulos said.

"The available data make a strong argument for the role of ED as an early marker of cardiovascular disease," he said. "ED should raise suspicions about early atherosclerosis, even in men who would not otherwise be considered at high risk."

A previous study by Dr Vlachopoulos showed that men with ED have increased expression of circulating inflammatory markers, such as C-reactive protein, interleukin-6, and tumor necrosis factor-alpha, as well as increased levels of endothelial prothrombotic markers, such as fibrinogen and von Willebrand factor.


  • The 14% rate of silent CAD among men with ED is much more serious than previously thought.
  • Erectile difficulties are often the first sign of asymptomatic CAD.
  • Absence of obstructive coronary lesions on angiography does not rule out acute coronary events.
  • Ask all men older than 30 years about potential erectile problems.