How erectile dysfunction may be an early sign of a heart attack or stroke

Cardiovascular diseases (CVD) encompass a group of disorders that includes coronary heart disease, cerebrovascular disease and peripheral arterial disease. The most common and well known complications from these disorders are a heart attack, stroke and intermittent claudication. The leading risk factors for CVD are age, high blood pressure, high cholesterol, smoking, diabetes in addition to being overweight and obese. Each contributes to the malfunctioning of the arteries affecting oxygenated blood flow to different organs and other parts of the body.

Endothelial dysfunction



The endothelium is the thin layer of cells that lines the arteries interiorly and which come in direct contact with blood flowing through. These cells are directly and indirectly involved in the dilation (expansion) and constriction (narrowing)of the artery. Also, normal functions of the endothelium involve the control of clotting, repair during an injury and the trafficking of substances like fluid, cells and minerals in and out of the artery.

Endothelial dysfunction is the term used to characterize the malfunctioning which results in reduced dilation (reduced blood flow), inflammation and a decreased control of clot formation and inhibition. Also, it is this dysfunction of the epithelium that leads to the thickening and hardening of the arteries known as atherosclerosis.


Atherosclerotic veins

Atherosclerotic veins

Atherosclerosis is a slow, progressive disease that may start as early as childhood. Described as a process where substances like cholesterol, waste products, calcium and clotting proteins build up along the endothelium. The build up that occurs in the diseased artery is called a plaque. The plaque may partially or completely block the flow of blood through an artery. The plaque may increase in size and decrease the diameter of the artery. Also, the plaque may break off the endothelium and plug up or block a smaller sized artery elsewhere. Finally, a partially or complete block may occur when a blood clot abnormally forms on the surface of the plaque. Each one reduces oxygenated blood flow through the artery and may result in a heart attack and stroke depending upon where it occurs 1.

Erectile Dysfunction as an early sign of CVD

Penis arteries

Penis arteries

An erection involves blood traveling through the peripheral arteries to fill chambers within the penis to create the firmness. Since the peripheral arteries are subjected to endothelial dysfunction and atherosclerosis, the arteries that supply the penis are also at risk. Erectile dysfunction (ED) and CVD have similar risk factors and such factors contribute to the leading cause of erectile dysfunction 2.

Erectile dysfunction has been shown to be a sign that endothelial dysfunction and atherosclerosis is actively occurring elsewhere in the body. Several studies have made an association between diseased arteries of the penis and other arteries, most importantly, the arteries of the heart or brain.

Researchers in Milan suggest that artery size is an important factor in regards to the onset of endothelial dysfunction and atherosclerosis. The evidence produced by their investigation suggest that smaller-sized arteries, like those which supply the penis, are affected by atherosclerosis earlier than the larger-sized arteries associated with the heart and brain 3.

A study conducted at the University of Chicago Hospitals found that peripheral arterial disease (PAD) was more common in men who also had erectile dysfunction. Data from questionnaires and the assessment of peripheral arteries by a test called the ankle brachial index (ABI) allowed researchers to conclude that erectile dysfunction is an independent predictor of PAD. Also, an increase in the severity of ED is associated with an increase in prevalence of PAD. The results suggest that men with ED may benefit from a screening ABI evaluation 4.

Another link was produced by a study published in Reviews in Urology. The researchers suggest that ED in an individual with known or unknown disease of the arteries that supply blood to the heart may be an early sign for the onset of unstable CHD caused by increased endothelial dysfunction. Unstable CHD is a warning sign that a heart attack may happen soon and is characterized by chest pain which is more severe, lasts longer, comes more often, occurs with less activity or even at rest 5.

Additionally, Taiwanese researchers in another study provided a link between ED as a marker for future stroke in men. So, if endothelial dysfunction and atherosclerosis affects the penis early, then ED could be utilized as a warning sign that a heart attack, stroke or intermittent claudication may follow. Further research have estimated that these serious events can occur as soon as 3 to 5 years after the onset of erectile dysfunction 6-7.

Preventable and modifiable risks

Current evidenced-based medicine has shown that lifestyle changes; lowering cholesterol, controlling blood pressure, losing excess weight and exercising more will reduce the risk of a heart attack or stroke. Researchers from the Mayo Clinic show that the symptoms of ED can be improved with similar changes. Additionally, treatment with medicines to lower blood pressure, cholesterol and control blood sugar may be incorporated. Medications like statins, which lower cholesterol have been shown to reduce the risk for a heart and stroke. With the knowledge that endothelial dysfunction and atherosclerosis are prominent causes of erectile dysfunction, men have a possible early warning sign that they may have CVD. Finally, there are different treatment options to lower your risk including the adoption of the lifestyle changes discussed earlier. Such lifestyle changes may reduce one’s risk for developing a heart attack and stroke in addition to treating erectile dysfunction 8.


  1. Inman BA, et al. A population-based longitudinal study of erectile dysfunction and future coronary artery disease. Mayo Clinic Proceedings. 2009; 84: 108.
  2. Stein RA. Endothelial Dysfunction, Erectile Dysfunction, and Coronary Heart Disease: The Pathophysiologic and Clinical Linkage. Rev Urol. 2003; 5(Suppl 7): S21–S27.
  3. Polonsky TS, et al. The association between erectile dysfunction and peripheral arterial disease as determined by screening ankle-brachial index testing. Atherosclerosis. 2009 Dec; 207(2): 440-4.
  4. Schwartz BG, et al. Cardiovascular implications of erectile dysfunction. Circulation. 2011; 123.
  5. Montorsi P, et al. Is erectile dysfunction the ‘tip of the Iceberg’ of a systemic vascular disorder? Eur Urol 2003; 44: 352–354.
  6. Kawanishi Y, Lee KS, Kimura K, Koizumi T, Nakatsuji H, Kojima K, et al. Screening of ischemic heart disease with cavernous artery blood flow in erectile dysfunctional patients. Int J Impot Res. Apr 2001; 13(2): 100-3.
  7. Chung SD, et al. Increased risk of stroke among men with erectile dysfunction: a nationwide population-based study. J Sex Med. 2011 Jan; 8(1): 240-6.
  8. American Urological Association. Management of Erectile Dysfunction. Available at sub=ed. Accessed February 9, 2011.