Erectile dysfunction and coronary plaque:
Is there a connection?
Men who experience erectile
dysfunction (ED) commonly
also have heart disease, and vice versa. If you have one,
you’re likely to have the other. Here’s a few things you can do about
it.
Henry, as usual, arrived for his appointment 15 minutes
early. This was his second visit since his heart attack four months
earlier. Before the heart attack, Henry had not seen a doctor in over 20
years. The heart attack really turned his life topsy-turvy.
On this occasion, everything checked out fine. However, Henry started
fidgeting and blurted, “Hey, doc, can I ask you about something?”
“Of course, Henry.”
“My wife and I haven’t had sex for about four years, even way before the
heart attack. It’s not like we need to do it all the time. But once in a
while it would be nice. What do you think about the drugs I keep seeing
on TV?”
It’s a familiar conversation I’ve had many times over the years. The
conversation has also changed with the introduction of the drugs for
impotence. Like many conditions, the drug manufacturers have managed to
reduce the issue down to need for a drug. But there’s a lot more to the
conversation than just prescribing a drug. And the conversation may have
particular relevance to our Track Your Plaque participants because 1)
the earlier a problem is addressed, the more likely a successful result
can be obtained and often without drugs, 2) impotence, or more
fashionably called “erectile dysfunction,” or ED, is common in men with
higher heart scan scores, and 3) many of the strategies that may improve
erectile function can also improve coronary health.
In the early years of my cardiology practice, I was struck by the number
of men with coronary disease who were also impotent. Closer questioning
often revealed a surprising fact: Men bashfully confessed that struggles
with erections usually began years before heart attack or other “event.”
In those days, impotence was blamed on the psychological disruption of
heart attack and heart procedures, the loss of control, the depression
that typically followed. It was so common that we also attributed it to
simple aging, the inevitable deterioration in virility, as common as
wrinkles and constipation.
Like many things, that old notion has fallen by the wayside along with
record players and snow tires.
ED and heart disease are closely tied together. We might even argue that
they represent the same disease, just expressed in two very different
ways.
The notion that heart disease and ED might share a common heritage
originated with studies like the Health Professions Follow-up Study that
showed that risk factors for coronary artery disease are identical to
those for ED. Hypertension, smoking, diabetes, high cholesterol, and
physical inactivity all strongly predict both conditions (Bacon CG al
2003).
ED is not something rare or uncommon. The Massachusetts Male Aging Study
of over 1000 men without heart disease between the ages of 40–70 years
showed that an astounding 50% of men at 50 years of age, 70% at 70 had
some degree of ED. Of the men with ED, 39% also developed heart disease
(Feldman HA et al 1994). A recent study of men with advanced coronary
disease documented 93% with ED 24 months before their heart attack or
onset of symptoms (Montorsi P 2006).
The men in our Track Your Plaque program for the most part have hidden
coronary plaque, but the majority come to the program before heart
attack, bypass surgery, stents or other more advanced manifestations of
coronary artery disease have developed. We would therefore expect that
ED is less common in our group. And that is true—but it’s still around
50%.
Erections don’t happen by accident
In their 20s and 30s, most men take the physical act of achieving an
erection for granted, as natural and automatic as sweating or digestion.
But a complex interplay of physiologic activities needs to be mounted
and precisely coordinated.
First of all, libido (interest in sex) is required, which triggers a
sympathetic (adrenaline-dependent) nervous system reaction mediated
through the thoracic spinal cord. Tactile stimulation, the pleasurable
sensation of touch, is mediated through the acetylcholine-dependent
parasympathetic nervous system. The circulatory system is required to
produce the familiar penile engorgement that defines an erection. The
cells lining the internal pudendal and penile arteries and all its
smaller branches are triggered to produce nitric oxide, the universal
artery-relaxing agent. Nitric oxide causes the arteries to enlarge,
increasing blood flow into penile tissues, followed by compression of
blood-draining penile veins, which causes blood to engorge the penis and
create an erection (Beckman TJ et al 2006).
Nitric oxide is crucial for a normal erection to proceed. It’s also the
weakest link in the sequence. Release of nitric oxide is readily
sabotaged by many conditions, including increased cholesterol, high
blood pressure, increased triglycerides, smoking, metabolic syndrome and
diabetes, excessive saturated fats or processed carbohydrates, among
others (Ignarro LJ et al 1999). The list of culprits that undermine
nitric oxide should seem familiar: Not only do they impair penile
erections, it’s the same list of culprits behind heart disease.
A disruption anywhere along the complex chain of events can impair the
capacity to have an erection. Any man or woman who has experienced the
frustration of male impotence knows that the consequences extend beyond
the physical—the embarrassment, tension, and fear that accompany it, all
adding up to a condition that creates far more than physical
dissatisfaction.
The most common reason for the erectile apparatus to fail is disruption
of the path leading to nitric oxide production and blood flow control.
Let’s take a closer look.
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Copyright 2007, Track Your Plaque.