News:Erectile dysfunction is associated with adverse cardiovascular events among diabetic patients
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May 20, 2008 By Vijayalakshmi Kunadian MBBS MD MRCP [1]
Italy and China: Two recent publications in the latest issue of JACC suggest that erectile dysfunction is associated with cardiovascular morbidity and mortality among diabetic patients with silent coronary artery disease.Erectile dysfunction (ED) once considered a psychological condition is now linked with adverse cardiovascular events among diabetic patients with stable silent coronary artery disease. Endothelial dysfunction has been demonstrated among patients with ED (in blood vessels that supply corpora cavernosa) and CAD. The blood vessels of corpora cavernosa have smaller reference diameter compared to the coronary arteries. This might explain the earlier occurrence of ED compared with the occurrence of adverse cardiac events at a later time period. Both these conditions are known to have common risk factors including hypertension, diabetes, hypercholesterolemia and smoking.
The first study (1) in the latest issue of JACC by Gazzaruso and coworkers from Italy evaluated 291 diabetic men with silent coronary artery disease with angiographic evidence of coronary artery disease enrolled between November 1998 and February 2006. Of these, 118 had ED and 173 did not. ED was assessed by the validated International Index Erectile Function-5 questionnaire. Patients were followed up for a period of 47.2±21.8 months. 61.2% of patients who developed major adverse cardiac event (MACE) and 36.4% of patients who did not develop MACE had ED (p=0.001). Regression analysis demonstrated that ED predicted the occurrence of MACE (HR 2.1, 95% CI 1.6 to 2.6, p<0.001). Furthermore, the use of statin (p=0.048) and 5-phosphodiesterase inhibitor (5-PDE) [p=0.032] were associated with lower rate of MACE among ED patients with CAD.
In the second study (2), Ma and coworkers studied a larger cohort of patients (n=2,306) who were followed up for 4 years (range 1.7 to 7.1 years). Of these, 26.7% had ED at baseline. ED was defined as per the definition of the National Institutes of Health Consensus Conference 1992. In this study, ED remained an independent predictor of coronary heart disease (HR 1.58, 95% CI 1.08 to 2.30, p=0.018) after adjustment for age, duration of disease and use of antihypertensive agents and albuminuria.
These two studies consisting of over 2,500 patients provide convincing evidence that ED is associated with adverse cardiac events. Management of patients with ED should include preventative strategies to reduce future cardiovascular events particularly among the diabetic population. It is therefore important to obtain a history of ED among diabetic patient population to identify those at risk of future cardiac events.
Sildenafil, a 5-PDE inhibitor previously studied as an antianginal agent, now is commonly used to treat ED and recently to treat patients with pulmonary hypertension. Given the benefit in terms of reduction in the MACE rate with sildenafil in the first study, in an accompanying editorial, Dr Kloner, from the Heart Institute, Good Samaritan Hospital, Los Angeles (3) indicated that “the time has come to study these agents systematically as potential therapies for the prevention of adverse cardiac events in patients with vascular risk factors”.
