Erectile Dysfunction and the Heart and Stroke Connection

Joseph R. Anticaglia MD
Medical Advisory Board

“There is a very strong link between erectile dysfunction (ED)and heart disease. Having ED is as much a risk factor for heart disease as a history of smoking or a family history of coronary artery disease,” says the Cleveland Clinic.

Studies have shown a 25% increased risk for heart attacks, strokes, angina, or mini-strokes in patients who initially seek help for ED. Also, a sizable number of these patients had undiagnosed hypertension and diabetes, according to the American Urology Association. Erectile Dysfunction is a warning sign of cardiovascular and metabolic problems. What is ED?

Erectile dysfunction is the inability to attain and maintain an erection sufficient for satisfactory sexual intercourse. It is estimated that 20 to 30 million men in America have been diagnosed with this condition. Failure to achieve an erection more than 50% of the time indicates a problem that requires evaluation and treatment.

Etiology (cause) of ED

Psychological and/or physical problems cause ED. To attain an erection there must be a proper stimulus from the brain; and the nerves and blood supply to the penis must be adequate. If any of these factors are missing, there will be an insufficient blood flow to the penis, and a man will not achieve a firm erection.

Table 1. Classification and Causes of Erectile Dysfunctions

Category Disorders Problem
Psychogenic Performance anxiety, Depression, Other psychiatric conditions Loss of libido, over-inhibition, Impaired nitric oxide release
Neurogenic Stroke, Spinal cord injury, Diabetic retinopathy Lack of nerve impulse, or Interrupted transmission
Hormonal Hypogonadism, Hyperprolactinoma Inadequate nitric oxide release
Vasculogenic (arterial or venous) Atherosclerosis, Hypertension Impaired arterial or venous flow
Medication-induced Antihypertensives, Antidepressants, Alcohol, Tobacco use Central suppression, Vascular insufficiency

American Urology Association, Erectile Dysfunction — Medical Student Curriculum

Risk Factors for ED

Metabolic syndrome: (high cholesterol, high blood sugar, high blood pressure, obesity). About 42% of men with diabetes experience ED (statistics vary).

Vascular diseases (atherosclerosis (blocked blood vessels), hypertension) account for seven out of ten cases of physical-related cases of erectile dysfunction in men over 60 years of age

Neurological diseases that interrupt the conduction of nerve impulses between the brain and the penis can lead to ED. For example, conditions such as injury to the spinal cord, stroke, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis (MS) cause men to experience ED.

Kidney disease can cause chemical changes that lower libido (sex drive).

Psychological issues:(anxiety, depression real, stress)
Excessive alcohol use
Traumatic injuries to the region, such as a fractured pelvis, radiation treatment for prostate cancer
Prescription Drugs, for example, blood pressure medications

Atherosclerosis (hardening of the arteries) …

is the buildup of cholesterol plaques on the inner walls of arteries causing obstruction to blood flow. It accounts for approximately 55% of physical-related cases of erectile dysfunction in men over the age of sixty.

Just as the coronary arteries can become blocked due to plaque formation, so too can the common penile artery become blocked due to plaque formation. The obstruction causes a decrease in blood flow to the penis which can lead to ED. Researchers report that erectile dysfunction signals the need to investigate the possibility of atherosclerosis, and medical conditions in other parts of the body.

NIH Atherosclerosis Normal artery and an artery with plaque buildup.


An in-depth medical history (medical, surgical, social, and psychological), physical examination, and appropriate laboratory test are required to make an accurate diagnosis. Three useful laboratory tests are:

Three Tests

  • Lipid Profile are blood tests used to evaluate fats in the blood, such as cholesterol and triglycerides. It evaluates your risk to develop CVD (cardiovascular disease) and used to monitor your response to treatment
  • Testosterone Level is a test that measures the blood level of the sex hormone testosterone. It can be low in patients with ED.
  • Hemoglobin A1C measures the average blood sugar level for the previous three months. It measures your risk for prediabetes (the likelihood to develop diabetes), and evaluates how well you’re managing your diabetes.


  • Healthy lifestyle
  • Medications
  • Counseling

We’ve heard it before about a healthy lifestyle, but it bears repeating because in the long run you’ll be healthier for exercising regularly, eating a healthy diet, maintaining a normal weight, not smoking, enjoying a happy relationship, being active in your community, minimizing stress, using alcohol in moderation and getting a good night’s sleep.

Medications such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) work by inhibiting the action of the enzyme PDE5 Nitrous oxide is needed for the muscles in the penis to relax. These drugs enhance the presence of nitrous oxide in the penis allowing smooth muscles to relax and increase the blood flow to the penis. For procedure options consult your urologist.


If emotional or psychological issues are affecting your ED, talk to your doctor about you and your partner seeking the advice of a counselor.

Erectile dysfunction is not just a sexual disease. It can be a precursor to future problems. As noted, ED is as much a risk factor for heart disease as a history of smoking. If risk factors are identified, they should be worked-up and treated promptly.


  1. Michael Böhm et al, Erectile dysfunction predicts cardiovascular events in high-risk patients receiving telmisartan, ramipril, or both: Circulation, Mar 30; 2010
  2. Cleveland Clinic; Heart Disease & Erectile Dysfunction; 17/2019.
  3. Martin M. Miner, MD; Erectile Dysfunction and the “Window of Curability;” Mayo Clin Proc.; Feb 2009 ED is “predominantly a disease of vascular origin with endothelial cell dysfunction.”
  4. Joseph R. Anticaglia, MD; Erectile Dysfunction and Metabolic Health; Doctor’s Column HC Smart, October 2016
  5. Joseph R. Anticaglia MD; Erectile Dysfunction and Oral Medications; Doctor’s Column HC Smart, October 2016


  1. PDE5 Inhibitors — Phosphodiesterase 5 Inhibitors
  2. Hemoglobin A1C (HbA1C) — this test measures the average amount of glucose that has been attached to hemoglobin over the past three months. It’s used to check for diabetes or prediabetes.

This article is intended solely as a learning experience. Please consult your physician for diagnostic and treatment options.