ED

From: http://www.medscape.com/viewarticle/575256_2

Erectile Dysfunction as a Harbinger for Increased Cardiometabolic Risk:

The MHI AlgorithmAuthors and DisclosuresPrint ThisShareFacebookTwitter processing.... Abstract and IntroductionThe MHI AlgorithmErectile Dysfunction as an Ideal Barometer of Atherosclerosis and Increased Cardiovascular RiskConclusionsReferencesThe MHI AlgorithmThe rationale for the MHI cardiovascular risk assessment and management algorithm (Figure 1) is based on the fundamental assumption that ED is an early clinical manifestation of systemic vascular disease. Any man aged 25 years and older who has persistent difficulty (lasting 3 months or more) in achieving or maintaining an erection should undergo a thorough cardiovascular risk assessment as part of the medical management for ED. The MHI Expert Advisory Panel believes that age 25 is a reasonable starting point, because the National Cholesterol Education Program Adult Treatment Panel III report recommends that a full-fasting lipid panel be obtained in men aged 20 and older,[12] and dyslipidemia is a well-documented risk factor for ED.[13](Enlarge Image)Figure 1.Minority Health Institute (MHI) Expert Advisory Panel's cardiovascular risk assessment and management algorithm for men with ED (reproduced with permission from KL Billups).[ CLOSE WINDOW ]Figure 1.Minority Health Institute (MHI) Expert Advisory Panel's cardiovascular risk assessment and management algorithm for men with ED (reproduced with permission from KL Billups).Workup for Cardiovascular RiskAll men with ED should be considered at increased risk for CVD until proven otherwise (Figure 1). The workup for cardiovascular risk factors in men with ED should include pertinent history (cardiac disease and other cardiovascular risk factors, lifestyle, tobacco and alcohol use, depression, current medications), appropriate laboratory measurements (blood pressure, fasting blood sugar, fasting lipoproteins, body mass index) and assessment for metabolic syndrome and/or insulin resistance. Assessment of cholesterol should include a routine fasting lipid profile (ongoing studies are investigating the potential role for the more advanced lipid particle size assays). Assessment for insulin resistance in overweight individuals can easily be performed using fasting insulin levels, fasting triglyceride levels or the triglyceride/high-density lipoprotein (HDL) cholesterol ratio.Given the emerging data revealing ED as an early manifestation of systemic vascular disease, aggressive medical management of cardiovascular risk factors is a reasonable clinical approach to ED in the primary care setting. Although the evidence base for the link between ED and CVD is still developing, it is reasonable to assume that most men with ED may have early clinical vascular disease and should be considered for management as secondary prevention patients according to the most stringent standards of existing guidelines. Such an approach to ED is similar to past associations between hyperlipidemia and coronary heart disease (CHD), where aggressive treatment protocols were developed long before the evidence was accumulated through clinical trials.Aggressive management of cardiovascular risk factors, as an adjunct to standard medical therapy for ED (that is, PDE5 inhibitors), is an important part of overall management of ED in primary care patients. For example, patients who smoke should be educated about smoking cessation and offered assistance in the form of medication and counseling.[14] Hypertension should be treated according to the guidelines of the Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Optimal blood pressure is <120/80 mm Hg, and a blood pressure of 120–139/80–89 mm Hg is considered to be prehypertensive. Patients with blood pressure ≥140/90 mm Hg should be managed with lifestyle modification and antihypertensive agents.[15]Current guidelines for management of elevated lipids are based on the underlying degree of cardiovascular risk. An optimal lipid panel would include the following values: low-density lipoprotein (LDL) levels <70 mg per 100 ml (in individuals classified as very high risk), HDL levels ≥40 mg per 100 ml, triglycerides <150 mg per 100 ml and total cholesterol <200 mg per 100 ml.[12] Given the evidence that many men with ED have clinical vascular disease, it seems reasonable for physicians to consider managing men with ED to optimal fasting lipid levels. Data from the Heart Protection Study[16] and the Anglo-Scandinavian Cardiac Outcomes Trial—Lipid Lowering Arm study[17] have shown the clear benefits of aggressive lipid lowering in men considered at increased risk for developing CVD. These benefits were seen despite the fact that their lipid levels were unremarkable.In addition, aggressive lowering of LDL levels using statins has been shown to improve erectile function in three recent clinical research studies.[18,19,20] Bank et al.[20] recently showed in a placebo-controlled study that both quinapril and atorvastatin significantly improved erectile function in men with moderate to severe ED taking 100 mg of sildenafil. Together these three studies provide further evidence supporting the contention that ED and CVD are causally linked and that pharmacologic treatment of the shared risk factors can improve both conditions simultaneously.An increasing number of persons in the United States have an especially lethal combination of major risk factors and body composition that together constitute a virulent pattern of cardiovascular risk known as metabolic syndrome. It has been estimated that 47 million persons in the United States have metabolic syndrome,[21] with a prevalence rate of more than 20%.[22,23] Hispanic Americans and African Americans are at particular risk of metabolic syndrome.[22,24] Persons with metabolic syndrome can be identified by a distinct pattern of abdominal obesity (waist circumference >40 inches in men), atherogenic dyslipidemia (triglycerides ≥150 mg per 100 ml, HDL <40 mg per 100 ml, small LDL particles and normal or slightly elevated LDL), hypertension (≥130/85 mm Hg), insulin resistance (fasting blood glucose ≥100 mg per 100 ml), and elevated levels of prothrombotic and proinflammatory markers.[25] Metabolic syndrome and insulin resistance are closely linked to ED. In one recently conducted study of 120 men with ED and no evidence of diabetes, 40% of patients fulfilled strict criteria for metabolic syndrome, and 73% were insulin resistant.[26]Workup for Vascular DiseaseIn addition to a workup for cardiovascular risk, all men who present with ED should be assessed for the presence and severity of vascular disease (Figure 1). High-risk patients with ED and clinical coronary artery disease should undergo exercise treadmill testing. In this context, high-risk patients are those with ED plus diabetes, three or more cardiovascular risk factors, angina or a CHD risk equivalent. Peripheral arterial disease, abdominal aortic aneurysm, symptomatic carotid artery disease, diabetes and multiple risk factors with a 10-year CHD risk greater than 20% constitute CHD risk equivalents.[12] Patients with ED and evidence of cerebrovascular disease should be assessed with carotid ultrasound. Symptoms of circulatory insufficiency that suggest peripheral vascular disease in men with ED should be evaluated using the ankle/brachial (A/B) index. Patients with an A/B index <0.90 should be managed with risk modification (smoking cessation, optimized treatment for hyperlipidemia, hypertension, diabetes), exercise and medications or surgery when needed.[27,28] It seems reasonable that at least men with ED who fall into the Princeton Conference indeterminate category (ED with three or more traditional cardiovascular risk factors)[10] are good candidates for evaluation with carotid ultrasound and/or A/B index testing. Future research studies may show that these additional tests are useful even in men who fall into the Princeton low-risk category.Recent clinical studies have investigated the prevalence of carotid and/or lower extremity arterial disease in men with vascular ED documented by penile ultrasound studies. One study found that penile artery insufficiency is associated with carotid and/or lower limb artery ultrasound abnormalities (atheroma or marked intima-media thickness) approximately 75% of the time.[29] Another study found that the severity of ED based on penile Doppler ultrasound correlates with associated ultrasound abnormalities in the carotid artery, lower limb arteries or both vascular beds. Men with ED and both carotid and lower limb abnormalities had the most severe penile artery disease based on ultrasound assessments of all three vascular beds.[30] Both of these studies support the concept that many men with vascular ED should be regarded as having generalized vascular atherosclerosis. Additional evaluation of the carotid and lower limb peripheral vascular beds may help to identify men who, after presenting with ED as their initial clinical symptom, would benefit from additional diagnostic testing and/or aggressive pharmacologic intervention for risk factor management.Workup for Erectile DysfunctionAll patients who present with ED should be worked up for cardiovascular risk as outlined above (Figure 1). In addition to a medical history, sexual history and physical examination, the proper assessment of ED requires selective laboratory tests, including fasting serum glucose or hemoglobin A1c, fasting lipid profiles and serum testosterone assays (total, free or bioavailable).[31,32,33] While a full review of testosterone therapy is beyond the scope of this article, in general, men with ED and symptoms of hypogonadism (diminished libido and erections, poor responders to PDE-5 inhibitor therapy, less energy, depressed mood, diminished muscle mass and strength) should be assessed with a morning total and free serum testosterone. Low testosterone levels (total testosterone less than 300 ng per 100 ml) in symptomatic men can identify potential candidates for testosterone replacement therapy. « Previous Page