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  • Review Article
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Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs

Nature Reviews Cardiology volume 19, pages 59–74 (2022)Cite this article

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Abstract

Sexual health has a fundamental role in overall health and well-being, and a healthy and dynamic sex life can make an important contribution to a good quality of life. Sexual dysfunction, and especially erectile dysfunction (ED) in men, is highly prevalent in patients with cardiovascular disease (CVD). CVD and ED have shared risk factors and pathophysiological links, such as endothelial dysfunction, inflammation and low plasma testosterone levels. ED has been shown to be an independent and early harbinger of future CVD events, providing an important window to initiate preventive measures. Therefore, screening and diagnosing ED is essential for the primary and secondary prevention of CVD because the assessment of ED offers an easy and low-cost prognostic tool that is an alternative to other investigational cardiovascular biomarkers. Moreover, ED is a major contributing factor to the discontinuation of, or poor adherence to, cardiovascular therapy. Cardiovascular drugs have divergent effects on erectile function, with diuretics and β-blockers having the worst profiles, and renin–angiotensin–aldosterone system inhibitors and nebivolol having the best profiles. Pharmacological treatment of ED has an equivocal effect on the risk of CVD, suggesting a complex interaction between ED and drugs for CVD. In this Review, we discuss how sexual function could be incorporated into the patient history taken by physicians treating individuals with CVD, not merely as part of the diagnostic work-up but as a means to pursue tangible and essential benefits in quality of life and cardiovascular outcomes.

Key points

  • Erectile dysfunction (ED) is common, especially with advancing age, and shares risk factors and pathophysiological mechanisms with cardiovascular disease (CVD).

  • ED is highly prevalent in men with CVD, often precedes a CVD event by 2–5 years and is a marker of general vascular disease.

  • ED predicts cardiovascular events and all-cause mortality especially in men with an intermediate CVD risk score, who need further evaluation for CVD.

  • Some CVD medications, such as β-blockers and diuretics, have a deleterious effect on erectile function, and physicians should be aware of these adverse effects.

  • Phosphodiesterase type 5 inhibitors are not only safe for the cardiovascular system but also seem to have beneficial effects on the vasculature that could explain promising results in prognostic studies.

  • Testosterone replacement therapy has shown conflicting results in terms of CVD risk and should be administered with close monitoring for possible adverse effects.

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Fig. 1: The shared pathways leading to ED and CVD.
Fig. 2: An algorithm for managing ED associated with cardiovascular drug therapy.
Fig. 3: Evaluation of ED and risk assessment for sexual activity in patients with CVD.

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Authors and Affiliations

  1. Cardiovascular Diseases and Sexual Health Unit, First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece

    Dimitrios Terentes-Printzios, Nikolaos Ioakeimidis, Konstantinos Rokkas & Charalambos Vlachopoulos

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  1. Dimitrios Terentes-Printzios
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All the authors researched data for the article. D.T.-P., N.I. and C.V. discussed the content of the article and wrote the manuscript. All the authors reviewed and edited the article before submission.

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Correspondence to Dimitrios Terentes-Printzios.

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K.R. reports travel grants and honoraria from Bayer, Eli Lilly, Menarini and Pfizer. C.V. reports study and travel grants and honoraria from Bayer, Eli Lilly, Menarini and Pfizer. The other authors declare no competing interests.

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Glossary

Vasculogenic ED

ED diagnosed using penile Doppler ultrasonography when the peak systolic velocity is <35 cm/s and/or when the end-diastolic velocity is >5 cm/s.

Vascular ageing biomarkers

Biomarkers that originate from changes in the function or structure of blood vessels with age, such as aortic stiffness, carotid intima–media thickness, coronary artery calcification and endothelial function.

Arterial stiffness

Reduced capacity of an artery to expand in response to changes in blood pressure.

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Terentes-Printzios, D., Ioakeimidis, N., Rokkas, K. et al. Interactions between erectile dysfunction, cardiovascular disease and cardiovascular drugs. Nat Rev Cardiol 19, 59–74 (2022). https://doi.org/10.1038/s41569-021-00593-6

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