Erectile Dysfunction and Your Heart: Why ED Can Be an Early Warning Sign

A man in his late forties, fit and well dressed, asked me quietly whether he could buy "something for erection problems" without seeing a doctor. When I asked a few routine questions, he mentioned that his father had a heart attack at fifty-two and that his own blood pressure had not been checked in years. He had come about erectile dysfunction and heart health without realizing the two were connected. I suggested he see his doctor first, and I told him why.

Erectile dysfunction (ED) means trouble getting or keeping an erection firm enough for sex. It is common, it is treatable, and it is nothing to be embarrassed about. It can also be an early sign that the blood vessels elsewhere in the body are not in good shape. This article explains the link in plain terms, what checks to ask for, and how to use ED medicines safely.

What ED is, and what causes it

The US National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says ED can be caused by conditions affecting blood vessels, nerves or hormones, as well as by medicines, mental and emotional factors and lifestyle. Among the blood vessel conditions it lists are atherosclerosis (narrowing of the arteries from fatty build-up), high blood pressure and stroke. Its risk factor list also includes diabetes, chronic kidney disease, obesity, low testosterone, an enlarged prostate, certain medicines, anxiety and depression, stress, too little physical activity, heavy alcohol use and smoking.

The NHS puts it simply. Occasional erection problems are common and often linked to stress, tiredness or drinking too much alcohol. Frequent problems may be linked to high blood pressure, high cholesterol, diabetes, depression or anxiety, or hormone problems, and some medicines can cause them.

Why ED can be an early warning sign

An erection depends on healthy blood flow, and the same artery damage that affects the penis can affect the heart and brain. Doctors often explain it this way: the arteries supplying the penis are small, so they may show the effects of narrowing earlier than larger arteries do. That is an explanation, not a proven mechanism, but the research supports the pattern.

• The PCPT analysis. A study published in JAMA in 2005 followed 9,457 men aged 55 and over from the placebo group of a large prostate cancer prevention trial, at 221 US centers. Among the men with no ED at the start, those who developed ED had about a 25% higher risk of later cardiovascular events, including heart attack, stroke and angina. Men with either new or existing ED had about a 45% higher risk. The authors suggested that a man who presents with ED should be screened for standard cardiovascular risk factors.
• Heart disease patients. A 2003 study in European Urology looked at 300 patients with chest pain and confirmed coronary artery disease. Of these, 147 (49%) had ED. In 67% of those, the ED had come first, on average 38.8 months before heart symptoms (range 1 to 168 months). The study had no comparison group, so it cannot prove ED predicts heart disease.
• Expert consensus. The Princeton III consensus panel, published in Mayo Clinic Proceedings in 2012, describes ED as a warning sign of future cardiovascular disease, especially in younger men, and recommends a thorough cardiovascular evaluation in men with ED. It notes that ED often occurs alongside silent heart disease that has no symptoms.

Please keep this in proportion. These are group averages. Most men with ED will not have a heart attack, and ED has many other causes. But because the check is simple, it makes sense to take the signal seriously instead of simply treating the symptom.

The checks worth asking for

A good assessment of ED looks at the whole man, not just the erection. The Princeton III panel suggests a medical and family history, a review of lifestyle, and relevant blood and urine tests. In practice, ask your doctor about:

• Blood pressure, measured properly and more than once.
• Cholesterol and blood fats.
• Blood sugar. An A1C or fasting glucose to check for prediabetes or diabetes.
• Kidney function.
• Testosterone. Princeton III recommends measuring it in men with ED of physical origin.
• Your medicines. Some antidepressants, blood pressure medicines, diuretics, antihistamines and others can contribute, according to the NIDDK. Do not stop any of them on your own. Heart medicines that protect you should not be withheld over concerns about sexual side effects, as an American Heart Association statement stresses. Talk to your prescriber if you are worried.
• Mood and stress. Anxiety and depression can be a cause and a result of ED.

If you have urinary symptoms, the NHS says a doctor may also examine your prostate.

What you can do for your heart and your erections

The NHS lists steps that help both: lose weight if you are overweight, stop smoking, eat a healthy diet, exercise regularly, manage stress, and keep alcohol to 14 units a week or less. It also notes that cycling for more than 3 hours a week may be a factor, so some men cut back for a while. These are the same measures that protect the heart, so effort goes twice as far.

Exercise matters in another way, too. For men who already have heart disease, the American Heart Association says sexual activity is generally reasonable for people with stable disease and low risk, but that those with unstable or severe symptoms should be stabilized first. Your cardiologist or doctor can judge where you stand.

ED medicines: how they work and how to stay safe

The main treatments are PDE-5 inhibitors: sildenafil (Viagra), tadalafil (Cialis), vardenafil and avanafil. The NHS explains that they increase blood flow to the penis. They need arousal to work and are not hormones or aphrodisiacs. In the UK, sildenafil can be prescribed or bought from a pharmacy after a consultation; the others need a prescription. In the US, all require a prescription.

Safety points I go through at the counter:

• Nitrates. The sildenafil label states plainly that it must not be used with nitrates, whether taken regularly or occasionally, because the combination can cause a dangerous drop in blood pressure. Nitrates include glyceryl trinitrate (GTN) spray and tablets, isosorbide mononitrate and isosorbide dinitrate. If you use any of these for chest pain, tell your prescriber and pharmacist and do not take a PDE-5 inhibitor. The label also bars use with riociguat, a medicine for pulmonary hypertension.
• Heart status. The label says these medicines are not for men for whom sexual activity is inadvisable because of their heart condition, and calls for caution after a heart attack, stroke or life-threatening arrhythmia in the past 6 months.
• Blood pressure medicines and alpha blockers. These can add to the blood pressure drop and cause dizziness. Your prescriber may start at a lower dose.
• Side effects. In the sildenafil label's trials, headache affected 16% of men on 25 mg, 21% on 50 mg and 28% on 100 mg, versus 7% on placebo. Flushing, indigestion and a blocked nose are also common.
• Rare but serious. An erection lasting more than 4 hours, sudden vision loss in one or both eyes, and sudden hearing loss or reduction all need emergency care, and the medicine should be stopped.

Beware of "natural" and online products

The US FDA has repeatedly found products sold as sexual enhancement supplements that secretly contain sildenafil or tadalafil. Its public notification for one such product warns that hidden ingredients may interact with nitrates and drop blood pressure to dangerous levels, and notes that people with diabetes, high blood pressure, high cholesterol or heart disease often take nitrates. In the UK, the NHS says many websites sell fake medicines and advises buying only from an online pharmacy registered with the General Pharmaceutical Council, with a doctor service regulated by the Care Quality Commission and doctors on the General Medical Council register.

In short, skip the roadside "herbal" packet or unknown website. A proper consultation costs far less than an emergency.

Questions to ask your doctor or pharmacist

• Could my ED be linked to my heart or blood vessels, and which checks do I need?
• Should my blood pressure, cholesterol, blood sugar and testosterone be tested?
• Might any of my current medicines be contributing?
• Is an ED medicine safe for me, given my heart health and my other tablets?
• Which one would suit me, and what side effects should I look out for?
• If I have chest pain or breathlessness when active, do I need a heart check before starting?
• Could counseling or stress management help?

If you'd like the full guide, my book Erectile Dysfunction: A Pharmacist's Honest Guide goes deeper into causes, medicines, heart health and getting your confidence back.

Sources

• National Institute of Diabetes and Digestive and Kidney Diseases. Symptoms and causes of erectile dysfunction
• NHS. Erectile dysfunction (impotence)
• Thompson IM, et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA. 2005;294(23):2996-3002. Summary in Urology Times
• Montorsi F, et al. Erectile dysfunction prevalence, time of onset and association with risk factors in 300 consecutive patients with acute chest pain and angiographically documented coronary artery disease. Eur Urol. 2003;44(3):360-365.
• Nehra A, et al. The Princeton III consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc. 2012;87(8):766-778. Summary on EurekAlert
• Levine GN, et al. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation. 2012;125(8):1058-1072. Summary in American Family Physician
• Pfizer. VIAGRA (sildenafil) prescribing information
• U.S. Food and Drug Administration. Public notification: Red Spartan 3000 contains hidden drug ingredients
• NHS. Heart attack