Number 28, 2005
Sex and the Heart

Erectile dysfunction as a marker of silent ischemia

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Michael Kirby
The Nevells Road Surgery, Letchworth Garden City, Herts, UK
Correspondence: Professor Michael Kirby, Hertfordshire Primary Care Research Network, The Surgery, Nevells Road, Letchworth Garden City, Herts SG6 4TS, UK.
E-mail: kirbym@globalnet.co.uk

Case report
A 44-year-old man presented in primary care in 1991, initially complaining of pain in the back. During the consultation, he also mentioned that he had been noticing difficulties with both achieving and maintaining an erection. A general enquiry by his practitioner about his lifestyle revealed that he was, in his words, “a stressed executive”. He was smoking 30 cigarettes a day, working long hours and drinking at least a bottle of red wine each night. He made time to play football each week, but otherwise had little leisure time. His blood pressure was normal, but no other clinical examination was made. It was noted that he was underweight and the discussion with his doctor focused on psychological causes for his erectile problems. He was advised to reduce his alcohol consumption, stop smoking and to try and find more time for leisure activities. He was offered the opportunity of a review, but did not return until he presented 5 months later with atypical chest pain, which led to his admission to hospital.
It was confirmed that the patient had suffered an inferolateral myocardial infarction, confirmed by increasing cardiac enzymes and typical changes on his electrocardiogram (ECG). Lipid tests showed an increased cholesterol concentration of 7.4 mmol/L, with increased concentrations of low-density lipoprotein cholesterol and reduced high-density lipoprotein cholesterol. Risk factors for coronary artery disease included a positive family history: his father had died of a myocardial infarct aged 56 years and his mother was hypertensive. He had been a regular smoker.
After this admission to hospital, the patient was discharged, but continued to experience ischemic pain. Medication included isosorbide mononitrate, diltiazem, and cholestyramine. He described a hollow sensation throughout his anterior chest occurring on a daily basis, with occasional radiation to his throat. The pain was precipitated by stress and overworking, but not by physical exertion. He experienced some pain every day, variable in intensity and duration, lasting several minutes, up to 24 h, and variably relieved by nitrates. He did not associate the pain with meals. He denied any tenderness in the chest wall and had not noticed any exacerbation of his symptoms with exertion.
In January 1992, the patient experienced a more severe episode of chest pain, which lasted several hours. He was re-admitted to hospital. ECG performed on the second admission (Figure 1) revealed T-wave inversion in the inferior and lateral leads and no acute ST-segment changes. A coronary angiogram was performed that showed left ventricular function to be slightly impaired. There was a 70% stenosis in the left anterior descending coronary artery after the first septal branch. There were no significant stenoses in the proximal right coronary artery, but there was a lesion in the obtuse marginal branch of the circumflex. A subsequent exercise tolerance test showed that he could achieve 12.5 min of exercise, but at this stage he developed chest pain and a 4 mm ST-segment depression in the anterior leads.

Comment
Since the early 1990s, there has accumulated a wealth of medical literature providing evidence that erectile dysfunction is an early sign of cardiovascular disease [2–5]. It is an important marker of vascular disease throughout the arterial tree, including coronary artery disease (CAD), stroke, and diabetes. Epidemiological studies have confirmed that there is a close association between erectile dysfunction and vascular disease. A study of 76 men with stable CAD showed that 75% had erectile dysfunction to some degree [6]. It is also recognized that risk factors for erectile dysfunction – hypertension [7], smoking [8], abnormal lipid profile [9], and diabetes [10–12] – are also risk factors for CAD. The link between erectile dysfunction and vascular disease is endothelial dysfunction [5,13,14].
The Massachusetts Male Aging Study, a random sample cohort of men aged 40–70 years, investigated the relationship between baseline risk factors for coronary heart disease (CHD) and subsequent erectile dysfunction (Figure 2). The premise was that subclinical arterial insufficiency might well first manifest itself as erectile dysfunction. Results in 513 men with no erectile dysfunction at baseline revealed that cigarette smoking almost doubled the risk of erectile dysfunction over 8–10 years of follow-up (24%, compared with 14% adjusted for age and covariates; P = 0.01). Being overweight (body mass index [BMI] >28 kg/m²) and a composite coronary risk score also significantly predicted incident erectile dysfunction. Associations were also seen for hypertension and dietary intake of cholesterol and saturated fat [15].

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