Erectile Dysfunction and Heart Disease

A non-invasive way to lower the risk

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Every once in a while, the World Health Organization gets something right. In this case, the WHO defines sexual health as:

“A state of physical, emotional, mental, and social well-being in relation to your sexuality. Sexual health requires a positive and respectful approach to pleasurable and safe sexual experiences which are consensual and free of coercion, discrimination, and violence.”

A healthy sex life is a key element for a healthy relationship with another consenting adult. Erectile dysfunction is often a major, disruptive hurdle. When men have this problem, it affects both parties, physically and psychologically.

Anatomy and Physiology

The development of an erection is a complex event involving integration of psychologic, neurologic, endocrine, vascular, and local anatomic systems. Arousal begins in the cortex of the brain and through a complicated neural network woven throughout the body, the parasympathetic nerves in the sacral area become activated. Nitric oxide increases inflowing arterial blood which compresses the penile veins, leading to the firmness needed for sexual activity.

Erectile dysfunction (ED) is defined as the recurrent or persistent inability to achieve and/or maintain an erection for satisfactory intercourse to occur. ED is a common health problem affecting men of all ages. Several studies have evaluated the prevalence of ED in the United States. The Massachusetts Male Aging Study reported a prevalence of 52%, with an increasing prevalence with age.

• Approximately 40% of men are affected at age 40.

• Nearly 70% of men are affected at age 70.

• Men in the older cohort (50 to 59) were more than 3 times as likely to experience erection problems and to report low sexual desire compared with younger men, aged 18 to 29.

Age was the variable most strongly associated with ED. Because the average lifespan in the US for men is 73 years and for women is 79 years, maintaining healthy sexual function as people move into their mature years is important for overall quality of life.

But ED may have much larger ramifications than an interruption of a healthy sexual relationship. A study published in 2018 the journal, Circulation stated:

Erectile dysfunction (ED) and cardiovascular disease (CVD) share common risk factors including hypertension, metabolic syndrome (obesity), diabetes, and smoking. 

Other risk factors associated with ED, reported in a Cleveland Clinic publication, include atherosclerosis, hyperlipidemia, depression, alcohol use, pelvic/perineal surgery or trauma, and neurologic diseases including strokes, multiple sclerosis, Parkinson’s disease, and spinal cord injuries.  

The underlying pathologies that connect ED and CVD are endothelial dysfunction, inflammation, and atherosclerosis (hardening of the arteries). More importantly, ED was found to be present in nearly 70% of subjects prior to the onset of cardiac symptoms, including angina.

A Long-Standing Warning Sign

As far back as 2003, an Italian study confirmed there is a strong relationship between ED and circulatory disease. Nearly 50% of patients (147 of 300) with coronary artery disease identified by cardiac catheterization reported significant erectile dysfunction. Among the findings were severe coronary artery blockages and markers of a poor cardiovascular prognosis.

A study from the University of Chicago published in 2006 in the Archives of Internal Medicine found erectile dysfunction to be an early warning sign. In the study, 221 men filled out a questionnaire that assessed erectile function prior to undergoing a stress test.

Almost 55 percent of the men (121 out of 221) suffered from erectile dysfunction. Those men, on average, had shorter exercise times and lower treadmill scores. Many had a low ejection fraction (a measure of the heart's pumping capacity.) In fact, 43% of the men with ED were "strongly associated” with clinically-significant coronary artery disease which includes a high risk of nonfatal myocardial infarction (heart attack) and cardiac death.

Researchers found that ED was a stronger predictor of significant coronary heart disease than any of the traditional “office-based risk factors” including family history, cholesterol levels, or elevated blood pressure.

Medications as Risk Factors

In addition to metabolic issues, a sizable list of medications can cause or can be attributed to ED. The following list an abbreviated list medications may cause or contribute to ED. You can find more specific medications on this list here.

• Alcohol, nicotine, and illicit drugs

• Analgesics

• Anti-convulsants

• Anti-depressants

• Anti-histamines

• Anti-hypertensives

• Anti-parkinson

• Anti-psychotics

• Cardiovascular agents (blood pressure medications)

• Diuretics

• Hormones and hormone-active agents

• Immunomodulators

• Tranquilizers

If a person taking one of these drugs is weaned off and the ED does not improve, most men are referred to a specialist to discuss additional treatment options. This includes invasive procedures such as intracavernous and/or intraurethral penile injections, vacuum constriction devices, and possibly surgery to implant a penile prosthesis.

These devices are not without risk, which can include problems from the anesthesia, device infection, and device malfunction. Mechanical failure rates of a specific type of prosthesis varies between devices, but overall, the percentage of devices that fail over a 5-year period ranges from 6% to 16%.

A Better Solution for ED and Overall Circulation

A noninvasive management alternative, which has been useful in patients with ED is external counterpulsation (ECP). This method is based on using a machine and cuffs to improve blood flow throughout the body.

ECP was first presented by Zheng, et.al. in 1983, he used serial cuff inflation to replace a hydraulic pump system that had been used for cardiac events since 1953 with a pneumatic system. The counterpulsation was synchronized with the cardiac cycle by EKG leads attached to the compressor’s motherboard. In 1995, the earliest randomized clinical trial study of ECP on patients with stable angina was conducted. Named the Multicenter Study of Enhanced External Counterpulsation, the results demonstrated a significant decrease in angina and a significant increase in exercise tolerance among patients treated with ECP.

How does ECP work?

ECP therapy includes three groups of cuffs, similar to large blood pressure cuffs, that are wrapped around each leg at the calf, the thighs, and the lower abdomen. Inflation of the cuffs is triggered at the end of the heartbeat (systole) when the myocardium (heart muscle) relaxes to fill with blood. When the heart beats, the cuffs relax/deflate. The result of this cyclic treatment is an overall improvement of blood flow throughout the body.

ECP treatment gently but firmly compresses the blood vessels in the lower limbs to increase blood flow to the heart and other organs. Each wave of pressure is electronically timed to the heartbeat, so that the increased blood flow is delivered to your heart at the precise moment it is relaxing. When the heart pumps again, pressure is released instantaneously. The pressure on the legs feels like a deep tissue massage and can be regulated for less or greater pressure.

ECP’s Impact on Society

In 2022,  there were between 50,000 and 100,000 new cases of refractory angina diagnosed in the US and between 30,000 and 50,000 new cases in Europe. By definition, refractory angina means that patients still experience debilitating chest pain with maximal medical therapy and after having a standard coronary revascularization procedure, such as a stent or by-pass surgery. In addition, congestive heart failure, the progression of chronic heart disease, affects more than 5.4 million individuals each year costing the US healthcare system nearly $31B per year, expected to increase to $50B by 2030.

ECP therapy, studied for more than 50 years now, is a safe, highly beneficial, low-cost, noninvasive treatment for a long list of problems associated with poor circulation. It can often reverse or improve both refractory angina and congestive heart failure. Evidence suggests that ECP therapy decreases long-term morbidity via several mechanism, including:

• Improved endothelial function (more nitric oxide)

• Promotion of collateral vessel growth (arteriogenesis and angiogenesis by increasing a hormone called VEGF)

• Improved strength and function of the heart’s pumping left ventricle (better ejection fraction)

• Improved oxygenation to all tissues (it is a passive exercise technique that has similar effects as aerobic training)

• Improved flow through all blood vessels, including the internal iliac and renal arteries, and to the arteries that supply the penis and genital area, hence, improved erectile function.

In Summary

ECP offers several other advantages, including:

• Non-invasive: It does not require surgery or medication.

• Well-tolerated: It generally has minimal side effects.

• Long-lasting results: It can provide sustained improvements in erectile function.

• Suitable and safe for those with underlying medical conditions.

• Extremely helpful for those who are completely healthy and want to stay that way!

As a non-invasive, non-pharmacological alternative to drug-based or invasive treatments, even healthy men can benefit from ECP therapy; studies have reported a significant change in the quality of erection in all age groups.

We have two clinics currently open to provide ECP therapy, with many more under development. One center is in Cleveland Ohio; the other is in Ventura, California. Patients have come to our wellness center in Cleveland from more than 25 states since we opened the center in July 2022. We hope to see you soon!

Additional References

• Froschermaier, et al. (1998) –  patients with average age 58yo – 20 treatments over 4 wks. (69%) reported a considerable improvement of the ability of sexual intercourse after ECP treatment and the average (mean) duration of response was 7.2 months. (We would recommend continual follow up with sessions 1-2 times per month. - ST)

• El-Sakkam, et al. (2007) – the more severe the underlying disease and the longer they have had ED and CVD, patients may need more than 35 treatments to achieve optimal resolution of ED symptoms.

• Lawson, et al. (2007) - cohort of 120 men in a multi-center study who had severe coronary artery disease and many cofounding health conditions completed 35 sessions at 1hr/d and 5d/wk. Comparison of the erectile functions scores pre- and post-ECP therapy demonstrated a significant improvement in erectile function, intercourse satisfaction, and overall satisfaction with the treatment.

• Manchanda, A. (2007) - numerous clinical trials in the last two decades have shown ECP therapy to be safe and effective for patients with refractory angina with a clinical response rate averaging 70% to 80%, which is sustained up to 5 years.