Erectile dysfunction: a harbinger or consequence: does its detection lead to a window of curability?

Erectile dysfunction (ED) is a marker of increased cardiovascular (CVS) risk and may indicate the need for aggressive evaluation for cardiovascular disease (CVD). In younger men with ED, the Framingham risk assessment has inadequate sensitivity. There is a need to develop a more sensitive risk-stratification protocol for this population. We sought to develop an algorithm for the evaluation and management of the ED patient. A search of literature published from 1998 to 2009 was performed. Search terms included the following: endothelial dysfunction; and erectile dysfunction combined with coronary artery disease (CAD), metabolic syndrome, or cardiac biomarkers. Searches revealed 107 references. These studies were evaluated with use of levels of evidence for the Centers of Evidence-Based Medicine. On the basis of these studies, recommendations for the evaluation and management of the patient with ED were developed. Newer, nontraditional markers and procedures may identify ED patients at risk for subsequent CVS events earlier or more easily than traditional risk assessments. Clear practice guidelines for risk stratification are being developed, and data are sufficient to propose an algorithm for these patients. The presence of ED should prompt assessment of cardiac risk and aggressive risk factor treatment. Available risk assessment factors should initially be used to stratify each patient. ED patients younger than 60 years of age and with no clinical CVD are at risk of CAD events (>10%) and should undergo further risk assessment. Additional tests of arterial damage and biomarkers may aid in refinement of risk for future cardiac events. Patients with ED can be classified into low-, intermediate-, and high-risk categories. A proposed algorithm can be used to direct the assessment of cardiometabolic risk in patients with ED.