Erectile dysfunction and heart health: why ED can be an early warning sign

Few men think of the bedroom as a place where heart disease announces itself, yet that is often where the first hint appears. The blood vessels that make an erection possible are affected by the same processes that narrow the arteries around the heart, and because they are so much smaller, they tend to show the strain sooner. Research over the past two decades has turned this observation into practical advice: new erectile dysfunction, especially in a man under 60, is a good reason to check his heart and circulation.

Why the penis and the heart are connected

An erection is fundamentally a blood flow event. When a man is aroused, the inner lining of the arteries (the endothelium) releases nitric oxide, which relaxes the smooth muscle in the vessel walls and lets blood rush into the penis. The same lining controls blood flow in arteries all over the body.

When that lining is damaged by high blood pressure, high cholesterol, smoking, high blood sugar or inflammation, it produces less nitric oxide and the arteries stiffen and narrow. This process, often called endothelial dysfunction, is the early stage of atherosclerosis.

Size explains the timing. The arteries supplying the penis are only 1 to 2 millimeters across, much narrower than the coronary arteries. A degree of narrowing that causes no heart symptoms at all can be enough to reduce blood flow to the penis. In effect, the penis can act as an early gauge of the health of the whole circulation.

What the research shows

ED predicts later heart problems

One of the most cited studies comes from the placebo group of a large US prostate cancer prevention trial. Researchers followed more than 9,000 men aged 55 and over for several years. Men who developed ED during the study had a higher risk of a later cardiovascular event, such as a heart attack or stroke, than men without ED. The authors noted that the increase in risk was similar in size to that from current smoking or a family history of heart attack.

ED often comes first

Studies of men who already have coronary artery disease have asked which came first. In one study of 300 men with both conditions, about two thirds said their erection problems started before any heart symptoms, by an average of a little over three years. Other research has reported a similar gap of two to three years. That window is an opportunity: time in which blood pressure, cholesterol and blood sugar can be treated before a heart attack or stroke.

Younger men are a particular focus

An international group of cardiologists and urologists, known as the Princeton Consensus, recommends treating ED as a possible sign of hidden vascular disease, and pays particular attention to younger men. In older men ED has many possible causes, but in a man in his 40s or 50s with no obvious explanation, it may be one of the first clues that his arteries need attention.

Shared risk factors

ED and heart disease share almost all their risk factors. If you have ED, it is worth asking whether any of these apply:

1. High blood pressure
2. High LDL cholesterol or triglycerides
3. Type 2 diabetes or prediabetes
4. Smoking, now or in the past
5. Carrying excess weight, especially around the waist
6. Low physical activity
7. A family history of early heart disease
8. Obstructive sleep apnea

Several of these are invisible without a test. Blood pressure, blood sugar and cholesterol can all be raised for years without symptoms, which is part of why ED is such a useful prompt to get them measured.

The heart check before ED treatment

Sex is a form of physical activity, roughly comparable to climbing two flights of stairs briskly. The Princeton Consensus recommends that doctors assess a man's cardiovascular risk and exercise capacity before starting ED treatment. In broad terms:

• Lower-risk men, without significant heart disease and able to manage moderate exercise, can usually be treated without further tests.
• Men at intermediate or uncertain risk may need further evaluation, such as an exercise test or review by a cardiologist, first.
• Higher-risk men, for example those with unstable angina, a recent heart attack or uncontrolled heart failure, should have their heart condition stabilized before sexual activity or ED treatment is considered.

This is also why ED medicines carry specific heart-related warnings. Tadalafil, for example, must never be taken with nitrate medicines for chest pain. Our guide to ED medication safety explains these in detail.

What to ask your doctor

If you are seeing a doctor about ED, these questions can help make sure your heart is not overlooked:

• Could my ED be related to my blood vessels?
• Should my blood pressure, cholesterol and blood sugar be checked?
• Is my heart healthy enough for sexual activity and for ED medicine?
• Do any of my current medicines affect erections or interact with ED treatment?
• What changes would do the most for both my heart and my erections?

Bring a list of everything you take, including supplements and any medicines you only use occasionally, such as chest pain sprays.

Treating the cause can help both

The good news is that the steps that protect the heart often help erections too. In a randomized trial of men with obesity, a two-year program of diet, exercise and weight loss improved erectile function, and the improvement tracked with weight lost, activity gained and lower levels of inflammation. Stopping smoking, controlling blood pressure and managing diabetes may all improve blood vessel health over time. Results vary, and some men will still need medication, but addressing the underlying risk factors is worthwhile regardless. Our guide to lifestyle changes for ED covers this in more depth.

Warning signs that need urgent care

Some symptoms should never be put down to ED or waited out. Call emergency services if you have:

• chest pain, pressure or tightness during or after sex
• sudden shortness of breath, fainting or a racing, irregular heartbeat
• sudden weakness on one side of the body, facial drooping or slurred speech

If you have taken an ED medicine such as tadalafil and develop chest pain, tell the emergency team which medicine you took and when, because it affects which heart treatments are safe to give. An erection lasting more than 4 hours, or a sudden loss of vision or hearing after taking an ED medicine, also needs prompt medical attention.

The takeaway

Erectile dysfunction is worth discussing with a doctor not only because it affects your sex life, but because it can be an early signal about your circulation. A simple set of checks can uncover problems that are much easier to treat early, and many of the changes that follow will benefit both your heart and your erections.

Sources

1. Thompson IM et al. Erectile dysfunction and subsequent cardiovascular disease. JAMA, 2005
2. Nehra A et al. The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clin Proc, 2012
3. Esposito K et al. Effect of lifestyle changes on erectile dysfunction in obese men. JAMA, 2004
4. Feldman HA et al. Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study. J Urol, 1994
5. National Institute of Diabetes and Digestive and Kidney Diseases: Symptoms and causes of erectile dysfunction
6. Tadalafil US prescribing information (DailyMed)

Related reading

• Erectile dysfunction overview: causes, options and when to see a doctor.
• What causes erectile dysfunction?: the full range of physical and psychological causes.
• ED medication safety: nitrates, heart conditions and interactions.
• Lifestyle changes for ED: habits that support blood vessels.
• Tadalafil for ED: how this PDE5 inhibitor works.

This article is for education only and is not a substitute for professional medical advice. Do not start, stop or change a medication without speaking to a licensed clinician. If you have chest pain, an erection lasting more than four hours, or sudden loss of vision or hearing, seek emergency care.