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Clinical significance of erectile dysfunction developing after acute coronary event: exception to the rule or confirmation of the artery size hypothesis?

Montorsi P, Ravagnani PM, Vlachopoulos C - Asian J. Androl. (2015 Jan-Feb)

Bottom Line: This is likely the result of smaller vessels (i.e. the penile artery) being able to less well tolerate the same amount of plaque when compared with larger ones (i.e. the coronary artery).If true, ED will develop before CAD.Reasons for this unusual sequence are discussed as they might still fit the ASH.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.

ABSTRACT
Erectile dysfunction (ED) has been found to frequently precedes the onset of coronary artery disease (CAD), representing an early marker of subclinical vascular disease, included CAD. Its recognition is, therefore, a "window opportunity" to prevent a coronary event by aggressive treatment of cardiovascular risk factors. The artery size hypothesis (ASH) has been proposed as a putative mechanism to explain the relationship between ED and CAD. Since atherosclerosis is a systemic disorder all major vascular beds should be affected to the same extent. However, symptoms at different points in the system rarely become evident at the same time. This is likely the result of smaller vessels (i.e. the penile artery) being able to less well tolerate the same amount of plaque when compared with larger ones (i.e. the coronary artery). If true, ED will develop before CAD. We present a case in which ED developed after a coronary event yet before a coronary recurrence potentially representing a late marker of vascular progression. Reasons for this unusual sequence are discussed as they might still fit the ASH.

No MeSH data available.


Related in: MedlinePlus

Number of major adverse cardiac and cerebrovascular events along the 5 years follow-up in the Thompson's study. AMI: anterior myocardial infarction; CHF: congestive heart failure; CV: cardiovascular; ED: erectile dysfunction; TIA: transient ischemic attack.
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Figure 5: Number of major adverse cardiac and cerebrovascular events along the 5 years follow-up in the Thompson's study. AMI: anterior myocardial infarction; CHF: congestive heart failure; CV: cardiovascular; ED: erectile dysfunction; TIA: transient ischemic attack.

Mentions: Finally, progression of cavernous (and coronary) atherosclerosis may be an alternative cause of ED after a coronary event especially if it lasts and/or worsens over time despite appropriate treatment of both psychologic and pharmacologic influences. In this occurrence, ED might represent a late warning sign of a flow-limiting coronary stenosis. The actual prevalence of ED after CAD is largely unknown. Available information came from the Thompson's study.29 The authors examined the association between ED and subsequent CVD in 9457 men enrolled in the placebo-arm of the Prostate Cancer Prevention Trial. Among 4247 men without ED at study entry, incident ED (defined as the first report of ED of any grade) developed in 57% after 5 years of follow-up and was associated with a significant higher rate of AMI/angina when compared to men without ED. Overall, among 486 cardiovascular events (i.e. AMI, angina, transient ischemic attack, CHF, fatal/nonfatal cardiac arrest, arrhythmias), 67% involved the coronary circulation (angina and/or AMI) and occurred in roughly half of the cases after ED diagnosis (ED prior to CAD). In patients with normal sexual function who had a cardiac event, ED either followed or never occurred in 55% and 45% of cases, respectively (Figure 5). Unfortunately, in those who actually develop ED after CAD, the lack of data about psychological, pharmacological and other potential influences hampers the interpretation of the reasons for the reverse temporal sequence. We do think that ASH may still explain this occurrence. In-fact, a progression of atherosclerosis will likely affect first the smaller artery (penile circulation) leading to new ED onset despite negative cardiological tests of inducible ischemia (Figure 6). Later in the follow-up, any further plaque growing will significantly reduce coronary lumen diameter accounting for both angina symptoms and ECG changes of ischemia during the stress tests. At this time, coronary angiography may show new lesions (Figure 7). If this holds true, ED developing late after a cardiac event may represent an “early sign” of vascular disease progression in patients with known CAD with a similar pathophysiologic mechanism as in the case of ED prior to CAD. We do not have data about the average time interval between ED and “new angina” (18 months in this specific patient). As for ED prior to CAD, the length of this time interval is the result of a balance between adverse (i.e. age, risk factor profile, duration of ED at the time of the first diagnosis) and protective factors (i.e. regular exercise program, appropriate diet and pharmacological treatment of risk factors). Whatever the length of this interval is, new onset ED should rise the suspicion of CAD progression, providing a window of opportunity for an aggressive risk reduction management in these patients.


Clinical significance of erectile dysfunction developing after acute coronary event: exception to the rule or confirmation of the artery size hypothesis?

Montorsi P, Ravagnani PM, Vlachopoulos C - Asian J. Androl. (2015 Jan-Feb)

Number of major adverse cardiac and cerebrovascular events along the 5 years follow-up in the Thompson's study. AMI: anterior myocardial infarction; CHF: congestive heart failure; CV: cardiovascular; ED: erectile dysfunction; TIA: transient ischemic attack.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4291870&req=5

Figure 5: Number of major adverse cardiac and cerebrovascular events along the 5 years follow-up in the Thompson's study. AMI: anterior myocardial infarction; CHF: congestive heart failure; CV: cardiovascular; ED: erectile dysfunction; TIA: transient ischemic attack.
Mentions: Finally, progression of cavernous (and coronary) atherosclerosis may be an alternative cause of ED after a coronary event especially if it lasts and/or worsens over time despite appropriate treatment of both psychologic and pharmacologic influences. In this occurrence, ED might represent a late warning sign of a flow-limiting coronary stenosis. The actual prevalence of ED after CAD is largely unknown. Available information came from the Thompson's study.29 The authors examined the association between ED and subsequent CVD in 9457 men enrolled in the placebo-arm of the Prostate Cancer Prevention Trial. Among 4247 men without ED at study entry, incident ED (defined as the first report of ED of any grade) developed in 57% after 5 years of follow-up and was associated with a significant higher rate of AMI/angina when compared to men without ED. Overall, among 486 cardiovascular events (i.e. AMI, angina, transient ischemic attack, CHF, fatal/nonfatal cardiac arrest, arrhythmias), 67% involved the coronary circulation (angina and/or AMI) and occurred in roughly half of the cases after ED diagnosis (ED prior to CAD). In patients with normal sexual function who had a cardiac event, ED either followed or never occurred in 55% and 45% of cases, respectively (Figure 5). Unfortunately, in those who actually develop ED after CAD, the lack of data about psychological, pharmacological and other potential influences hampers the interpretation of the reasons for the reverse temporal sequence. We do think that ASH may still explain this occurrence. In-fact, a progression of atherosclerosis will likely affect first the smaller artery (penile circulation) leading to new ED onset despite negative cardiological tests of inducible ischemia (Figure 6). Later in the follow-up, any further plaque growing will significantly reduce coronary lumen diameter accounting for both angina symptoms and ECG changes of ischemia during the stress tests. At this time, coronary angiography may show new lesions (Figure 7). If this holds true, ED developing late after a cardiac event may represent an “early sign” of vascular disease progression in patients with known CAD with a similar pathophysiologic mechanism as in the case of ED prior to CAD. We do not have data about the average time interval between ED and “new angina” (18 months in this specific patient). As for ED prior to CAD, the length of this time interval is the result of a balance between adverse (i.e. age, risk factor profile, duration of ED at the time of the first diagnosis) and protective factors (i.e. regular exercise program, appropriate diet and pharmacological treatment of risk factors). Whatever the length of this interval is, new onset ED should rise the suspicion of CAD progression, providing a window of opportunity for an aggressive risk reduction management in these patients.

Bottom Line: This is likely the result of smaller vessels (i.e. the penile artery) being able to less well tolerate the same amount of plaque when compared with larger ones (i.e. the coronary artery).If true, ED will develop before CAD.Reasons for this unusual sequence are discussed as they might still fit the ASH.

View Article: PubMed Central - PubMed

Affiliation: Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.

ABSTRACT
Erectile dysfunction (ED) has been found to frequently precedes the onset of coronary artery disease (CAD), representing an early marker of subclinical vascular disease, included CAD. Its recognition is, therefore, a "window opportunity" to prevent a coronary event by aggressive treatment of cardiovascular risk factors. The artery size hypothesis (ASH) has been proposed as a putative mechanism to explain the relationship between ED and CAD. Since atherosclerosis is a systemic disorder all major vascular beds should be affected to the same extent. However, symptoms at different points in the system rarely become evident at the same time. This is likely the result of smaller vessels (i.e. the penile artery) being able to less well tolerate the same amount of plaque when compared with larger ones (i.e. the coronary artery). If true, ED will develop before CAD. We present a case in which ED developed after a coronary event yet before a coronary recurrence potentially representing a late marker of vascular progression. Reasons for this unusual sequence are discussed as they might still fit the ASH.

No MeSH data available.


Related in: MedlinePlus