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Sex Life May Offer Clues to CVD Risk
A comprehensive approach to cardiovascular risk reduction in men should include evaluation of sexual function, which might identify those who require further cardiovascular assessment, according to updated consensus recommendations.
Erectile dysfunction (ED) has similar or better predictive value for cardiovascular events than do traditional cardiovascular risk factors and often occurs within the context of silent coronary artery disease (CAD). Several studies have documented a time window of 2 to 5 years between onset of ED and a CAD event.
Moreover, evidence suggests ED has predictive value for peripheral arterial disease and stroke.
"ED and cardiovascular disease (CVD) share risk factors, and ED is an independent predictor of CVD," Ajay Nehra, MD, of the Mayo Clinic in Rochester, Minn., and co-authors of the Princeton III Consensus Conference recommendations wrote in the August issue ofMayo Clinic Proceedings.
"Thus, assessment of sexual function should be incorporated into the initial cardiovascular evaluation for all men, regardless of the presence or absence of known CVD."
Initially developed in 1999, the Princeton Consensus Conference recommendations offer multidisciplinary guidance to clinicians about optimizing sexual function and preserving cardiovascular health in men and women. Over time, the scope and focus of the recommendations have evolved to reflect accumulating evidence about the relationship between sexual function and CVD.
The first recommendations focused on stratification of patients with existing CVD by the level of cardiac risk associated with sexual activity (Am J Cardiol 2000; 86: 175-181). The second consensus panel expanded the recommendations to include all men with ED and incorporated information on use of phosphodiesterase type 5 (PDE5) inhibitors in the management of ED (Am J Cardiol 2005; 96: 313-321).
The third consensus panel, convened in November 2010, focused on three areas: evaluation and management of cardiovascular risk in men with ED but not CVD; updating the recommendations for evaluating cardiac risk associated with sexual activity in men with known CVD; and the role of testosterone replacement therapy (TRT) in managing ED and CVD.
Assessment and risk clarification have two guiding principles: A man with organic ED should be considered at increased risk of CVD until proven otherwise. ED increases CVD risk even in the absence of CVD symptoms or history. Accordingly, the panel recommended the following assessments:
- Medical history
- Physical exam
- ED severity assessed by a validated scale
- Resting electrocardiogram
- Fasting glucose
- Serum creatinine level and albumin:creatinine ratio
- Lipid profile
Additionally, the consensus panel recommended measuring testosterone levels in all men who have organic ED, particularly those who have not responded to treatment with a PDE5 inhibitor. The recommendations include a lengthy discussion of recent evidence surrounding the clinical implications of low serum testosterone and the potential benefits of TRT.
The panel also reviewed other organizations' recommendations regarding evaluation and testing for ED and CVD, the evidence supporting the recommendations, and the application of the recommendations to subgroups of patients.
The consensus group provided an algorithm for managing ED in patients with known CVD. Sexual inquiry of all men is recommended, and those with ED should have an assessment of their exercise capacity. Exercise tolerance should help clinicians categorize patients as high, intermediate, or low risk, in keeping with accepted criteria (such as New York Heart Association functional classes).
Most low-risk patients can initiate or resume sexual activity and begin ED treatment without further testing or evaluation. High-risk patients should be referred to a cardiologist before initiating PDE5 therapy.
"Consistent with other guidelines, the recommendations of the third Princeton Consensus Panel emphasize an approach to risk assessment that integrates multiple aspects of cardiometabolic health," the authors wrote in their summary. "Sexual function should be incorporated into CVD risk assessment for all men, and ED may allow identification of at-risk men who require further cardiovascular evaluation.
"The scientific evidence suggests that a comprehensive approach to cardiovascular risk reduction will improve overall vascular health, including sexual health."
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The authors disclosed relationships with Pfizer, Eli Lilly, Bayer, Abbott Laboratories, Auxilium Pharmaceuticals, Boehringer Ingelheim, Endo Pharmaceuticals, GlaxoSmithKline, Timm Medical Technologies, VIVUS, Shionogi, Nextmed, Merck, Gilead, Roche,Vydox, Coloplast, Medtronic Vascular, Slate Pharmaceuticals, BioSante Pharmaceuticals, Target Health, Repros Therapeutics, Merck/Schering, Palatin Technologies, Forest Laboratories, sanofi-aventis, Novartis, Actient, and Galapagos NV.
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