Erectile dysfunction and the heart: what the research shows

Is erectile dysfunction a sign of heart disease? In many men the two are linked, and the research on the link is strong. Two meta-analyses of long-term studies, one of 36,744 men and one of 92,757, found the same thing. Men with erectile dysfunction (ED) went on to have more heart attacks and strokes than men without it.

The size of that link is modest, and it depends on age. In the 2013 meta-analysis of 14 studies, ED was linked to a risk of heart and blood vessel events about 44% higher. A Mayo Clinic study found the signal strongest in men in their 40s and weak in men over 70. ED has many causes, and in the studies most men with ED had no heart event during follow-up.

What is erectile dysfunction, and why would it involve the heart?

Erectile dysfunction means trouble getting or keeping an erection firm enough for sex. It is common. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) estimates that 30 million to 50 million US men have it. It says about 40% of men are affected at age 40 and about 70% by age 70. NIDDK also says ED "may be a symptom of another health problem."

An erection depends on blood flowing into the penis. Atherosclerosis is the build-up of plaque inside arteries. The National Heart, Lung, and Blood Institute (NHLBI) says it can affect almost any artery in the body. It lists ED among its possible complications, along with heart attack and stroke. The causes of ED that NIDDK names overlap with heart risks. They include high blood pressure, diabetes, obesity, smoking and too little physical activity.

In a 2005 paper, Montorsi and colleagues set out what they call the artery size hypothesis. The arteries of the penis are smaller than the arteries of the heart. So, they suggested, the same amount of plaque could limit blood flow to the penis before it causes chest symptoms. It is a proposed explanation, not a measured finding.

What did the studies find?

The two largest summaries are meta-analyses of cohort studies, which follow men over years. In 2011, Dong and colleagues pooled 12 studies of 36,744 men in the Journal of the American College of Cardiology. Men with ED had a 48% higher risk of heart and blood vessel disease. Their risk of stroke was 35% higher, and of death from any cause 19% higher. The authors judged the link "probably independent" of the usual risk factors.

The 2013 meta-analysis, led by Vlachopoulos, pooled 14 studies of 92,757 men, with an average follow-up of 6.1 years. ED was linked to a 62% higher risk of heart attack and a 25% higher risk of death from any cause. The rise in deaths from heart disease itself, 19%, was not statistically significant.

One study came from a prostate cancer prevention trial. Thompson and colleagues followed the 9,457 men in its placebo group, reporting in JAMA in 2005. Of the 4,247 men with no ED and no heart disease at the start, 2,420 developed ED. Those men had a 25% higher risk of a later heart event. The authors called ED a warning sign "in some men."

Age changes the picture. Inman and colleagues followed 1,402 men in Olmsted County, Minnesota, from 1996 to 2005. Among men aged 40 to 49, new heart disease occurred at 0.94 cases per 1,000 person-years without ED. With ED, the rate was 48.52. Among men 70 and older, the rates were 23.30 and 29.63, a small difference.

Two hospital studies asked men with heart disease when their erection problems began. In a 2003 study of 300 men with chest pain and narrowed arteries, 49% had ED. In two-thirds of those men, ED came first, by an average of 38.8 months. A 2006 study, called COBRA, put the lead time at 2 to 3 years.

Where is the link oversold?

ED is sometimes described as a sure sign of a coming heart attack. The studies do not show that. The raised risks in the meta-analyses were between about 19% and 62%, which is a higher risk, not a diagnosis. ED is also very common, and the NHS says occasional problems are usually caused by stress, tiredness or alcohol.

The "2 to 3 years" lead time is often quoted as a rule. It comes from small hospital groups of men who already had heart disease, not from following healthy men forward. In the COBRA study, only 22% of men with a single narrowed vessel had ED.

Lifestyle claims also run ahead of the evidence. The trials of weight loss and exercise measured erection scores, not heart attacks. Supplements sold for erections are a separate concern. The National Center for Complementary and Integrative Health (NCCIH) has looked at herbal products for ED. It says there is "no definite evidence" that any is safe or effective. The FDA says many such products contain hidden drug ingredients.

What did the lifestyle trials use?

Esposito and colleagues reported one such trial in JAMA in 2004. It followed 110 obese men aged 35 to 55 with ED for 2 years. The 55 men in the lifestyle group aimed to lose at least 10% of their weight and to move more. Their weekly activity rose from 48 to 195 minutes, and their average body mass index fell from 36.9 to 31.2.

Their scores on the International Index of Erectile Function rose from 13.9 to 17. The control group stayed at about 13.6. By the end, 31% of the lifestyle group scored 22 or higher, against 5% of controls.

A 2011 meta-analysis by Gupta and colleagues pooled 6 trials and 740 men. It looked at lifestyle changes and at drugs that lower heart risk, such as statins. Scores on a short erection questionnaire, the IIEF-5, rose by 2.66 points. The 2012 Princeton III consensus statement focuses on finding men with ED who may need further heart checks.

What do the warnings say?

The US Centers for Disease Control and Prevention (CDC) lists the main signs of a heart attack. They include chest pain or discomfort, pain in the jaw, neck, back, arms or shoulders, shortness of breath and feeling faint. The CDC says to "call 9-1-1 immediately." The US National Library of Medicine's page on sildenafil, one ED medicine in the PDE-5 inhibitor class, warns about nitrates, a group of heart medicines. It says people taking nitrates need to tell their doctor. It also says to call a doctor at once about chest pain, dizziness or nausea during sex. NIDDK says an erection lasting more than 4 hours needs medical help right away.

Questions to Ask Your Doctor

• Is there a reason my ED could be related to my heart or blood vessels?
• Should my blood pressure, cholesterol or blood sugar be checked because of my ED?
• Could any of my current medicines be affecting my erections?
• Is my heart healthy enough for sexual activity?
• Could an ED medicine interact with anything I take, including nitrates?

Questions People Ask

Does erectile dysfunction mean I will have a heart attack?

No study shows that. The meta-analyses found a higher average risk across groups of men, not a certainty for any one man. The Thompson study reported unadjusted rates. Heart events ran at 0.024 per person-year in men with ED and 0.015 in men without. That is about 2.4 events per 100 men per year with ED, and 1.5 without.

Does the link matter more for younger men?

The studies suggest it does. In the Mayo Clinic study of Olmsted County men, the gap in heart disease rates was widest for men in their 40s. The 2013 meta-analysis also found a stronger link in younger men. In men 70 and older, the authors found ED told them little about future heart risk.

Can heart health affect erections later on?

The Multi-Ethnic Study of Atherosclerosis looked at this in a 2017 paper. Among 1,136 men, those with the highest heart-health scores at the start later had ED less often. ED was reported by 33% of men with high scores and 58% of men with low scores. The study shows an association, not cause and effect.

Are herbal ED supplements safe?

NCCIH says many supplements sold for sexual enhancement have been found to contain hidden drug ingredients. It says some can interact with nitrate medicines and cause a dangerous drop in blood pressure. The FDA keeps a list of contaminated products and says the list covers only a small fraction of them.

For the wider picture, see our overview, Sexual health basics, from the research.

Pictures and credits

In pictures

The Healing Spot reports published research for general information. It is not medical advice and does not replace a doctor, who knows your history. Talk to a qualified clinician before you start, stop or change any treatment, supplement or practice. If you think you may have a medical emergency, call 911 or your local emergency number.