2/23/2015 1 February 23, 2015 1 Erectile Dysfunction: An Early Sign of Cardiovascular Disease Recommendations for the Evaluation of CVD Risk in Patients with Vascular ED Presented by: Michael J. Blaha MD MPH Penile Anatomy Vascular Causes of ED Arterial Stenosis Impaired Vasodilation Atherosclerosis Impairment of endothelium-dependent relaxations Smooth muscle Atrophy and fibrosis Impaired relaxation Hypertension Hypercholesterolemia Diabetes Arterial insufficiency Reduced inflow Excessive outflow Arteries Corporo-veno occlusive disease Impairment Of neurogenic relaxations Trabeculae Trabeculae Arteries Adapted from: Saenz de Tejada I, et al. Erectile Dysfunction. Plymbridge Distributors; 2000;65-102 Functional Changes Structural Changes
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Blaha Erectile Dysfunction SUN 920 am · Initiate or resume dysfunction sexual activity or TTx*x for sexual * for sexual Sexual activity deferred until stabilization of cardiac condition
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2/23/2015
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February 23, 2015 1
Erectile Dysfunction: An Early Sign of Cardiovascular Disease
Recommendations for the Evaluation of CVD Risk in Patients with Vascular ED
Presented by: Michael J. Blaha MD MPH
Penile Anatomy
Vascular Causes of ED
ArterialStenosis
ImpairedVasodilation
AtherosclerosisImpairment of
endothelium-dependentrelaxations
Smooth muscleAtrophy and fibrosis
Impairedrelaxation
Hypertension
Hypercholesterolemia
Diabetes
Arterial insufficiency
Reduced inflow
Excessive outflow
Arteries
Corporo-venoocclusive disease
ImpairmentOf neurogenic
relaxations
TrabeculaeTrabeculae
Arteries
Adapted from: Saenz de Tejada I, et al. Erectile Dysfunction. Plymbridge Distributors; 2000;65-102
Functional ChangesStructural Changes
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Vascular ED: Early Marker of More Diffuse Vascular DiseaseVascular ED: Early Marker of More Diffuse Vascular Disease
Smaller penile arteries suffer obstruction from plaque burden earlier than the larger arteries
ED may be silent to the patient and healthcare prov ider — BUT THE VASCULAR DISORDER LINK WITH ED IS NOT CLINICALLY SI LENT
Vascular ED: Early Marker of Endothelial Dysfunction
Arteriole
lumen
Endothelium
SmoothSmooth
musclemuscle
Erectile Dysfunction & Cardiometabolic
RiskDyslipidemia
HBP
Diabetes CAD
Dyslipidemia
PENIS
HBP
Diabetes CAD
PENIS
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Erectile Dysfunction and Subsequent Cardiovascular Disease
Thompson IM, Tangen CM, Goodman PJ, Probstfield JL, Moinpour CM, Coltman CA. JAMA. 2005;294:2996-3002.
Erectile Dysfunction and Subsequent Cardiovascular Disease
Thompson IM, Tangen CM, Goodman PJ, Probstfield JL, Moinpour CM, Coltman CA. JAMA. 2005;294:2996-3002.
Does ED Predict CVD in an Asymptomatic Male?
Study PopulationStudy Population
• 9457 men age 55+ in the Prostate Cancer Prevention Trial randomized to placebo
– 8063 (85%) men with no CVD at study entry• 3816 (47%) reported some level of ED
at study entry• 4247 (53%) reported no erectile
dysfunction at study entry
Thompson et al. JAMA. 2005;294:2996-3002.
Study ResultsStudy Results
• 2420/4247 (57%) of men with no ED at study entry reported incident ED after 5 years.
• This increased to 65% at 7 years.• Incident ED was statistically significantly
associated with subsequent angina, myocardial infarction, and stroke relative to men without reported ED after adjusting for potential confounders (HR 1.25 – 1.45).
• Risk ~ smoking or a family history of CHD
Thompson et al. JAMA. 2005;294:2996-3002.
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10Thompson et al. JAMA. 2005;294:2996-3002.
Study Results
Does ED Precedes CVD?Does ED Precedes CVD?Prostate Cancer Prevention Trial (PCPT): Placebo Gr oupProstate Cancer Prevention Trial (PCPT): Placebo Gr oup
Time to Any Cardiovascular Event From Initial Repor t of ED for those with Incident ED and No Previous Cardiovascul ar Event.
Per
cent
age
With
Car
diov
ascu
lar
Eve
nt
At risk, n = 2495; number of cardiovascular events, 255; 5-year estimate of cardiovascular events, 11% .
No. at Risk 2495 2096 1551 776
Time Since Initial Erectile Dysfunction, y
20
15
10
5
01 2 3 4 5 6 7
The longer patients have had ED, the higher the likelihood of CVD event.
Thompson et al. JAMA. 2005;294:2996-3002.
A Population-Based, Longitudinal Study of Erectile Dysfunction and Future Coronary Artery Disease
Inman B, St. Sauver J, Jacobson D, McGree M, Nehra A, Jacobsen S. Mayo Clinic Proceedings. 2009;84:108-13.
Are the Same Associations Seen in a Community-Based Sample?
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• 1,402 community-dwelling men, enrolled in an Olmsted County (Minnesota) substudy, with regular sexual partners without known CAD were screened biennially for presence of ED
• Occurred from January 1996 to December 2005, a period of 10 years
• Adjusted CAD Incidence was calculated after age stratification and adjustment for cofounders
Study Population
Inman B, et al. Mayo Clinic Proceedings. 2009;84:108-13.
Study ResultsStudy Results
• Prevalence of ED was 2%, 6%, 17% and 39% in men aged 40-49, 50-59, 60-69, and 70+ years respectively.
• CAD incidence per 1000 person-years for men without ED was 0.94 (age 40-49), 5.09 (age 50-59), 10.72 (age 60-69), and 23.3 (age 70+).
• For men with ED: incidence of CAD was 48.52(age 40-49), 27.15 (age 50-59), 23.97 (age 60-69), and 29.63 (age 70+)
Inman B, et al. Mayo Clinic Proceedings. 2009;84:108-13.
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Inman B, et al. Mayo Clinic Proceedings. 2009;84:108-13.
Important Age Interaction!!
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Does ED Provide a “Window of Opportunity” for
Detecting and Treating Otherwise Unheralded CVD
Risk?
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Focused on clearing a patients for sexual activity and ED treatment
Princeton I Guidelines
Initiate or resumeInitiate or resume
dysfunctiondysfunction
Initiate or resumeInitiate or resumesexual activitysexual activity
ororTxTx* for sexual * for sexual dysfunctiondysfunction
Sexual activitySexual activitydeferred untildeferred untilstabilization ofstabilization ofcardiac conditioncardiac condition
Sexual InquirySexual Inquiry
EvaluationEvaluationClinicalClinical
EvaluationEvaluation
Low RiskLow Risk Indeterminate RiskIndeterminate Risk High RiskHigh Risk