Prognostic value of exercise capacity among men undergoing pharmacologic treatment for erectile dysfunction: The FIT Project

Erectile dysfunction and diabetes: A melting pot of circumstances and treatments

Diabetes mellitus (DM), a chronic metabolic disease characterised by elevated levels of blood glucose, is among the most common chronic diseases. The incidence and prevalence of DM have been increasing over the years. The complications of DM represent a serious health problem. The long-term complications include macroangiopathy, microangiopathy and neuropathy as well as sexual dysfunction (SD) in both men and women. Erectile dysfunction (ED) has been considered the most important SD in men with DM. The prevalence of ED is approximately 3.5-fold higher in men with DM than in those without DM. Common risk factors for the development of DM and its complications include sedentary lifestyle, overweight/obesity and increased caloric consumption. Although lifestyle changes may help improve sexual function, specific treatments are often needed. This study aims to review the definition and prevalence of ED in DM, the impact of DM complications and DM treatment on ED and, finally, the current and emerging therapies for ED in patients with DM.

Association Between Penile Color Doppler Ultrasonography and Cardiorespiratory Fitness in Patients With Vascular Erectile Dysfunction

INTRODUCTION

Vascular erectile dysfunction (ED) is a burdensome condition, associated with increased cardiovascular risk. Peak systolic velocity (PSV) represents the maximum pulse velocity in the cavernous artery measured by a penile color doppler ultrasonography (PCDU) during a pharmacologically induced erection and is considered a reliable parameter for the diagnosis of vascular ED. However, the cut-off value of standard PSV (30 cm/s) provides high sensitivity only in the diagnosis of advanced arteriogenic disease. Thus, an age-adjusted PSV (6.73 + 0.7 x age cm/s) has been proposed to offer a more accurate diagnosis of vascular ED.

AIM

In this study it was aimed to answer the following question: "Is there any positive association between indexes of vascular erectile dysfunction and cardiorespiratory fitness?"

MAIN OUTCOME MEASURE AND METHODS

25 patients with a medical history of ED (median age 55.3 years) underwent PCDU after pharmacological stimulation. Subsequently, a functional evaluation with ECG-monitored, incremental, maximal cardiopulmonary exercise testing was performed.

RESULTS

Peak oxygen uptake (VO2 peak), peak oxygen uptake per body weight (VO2 peak/kg) and Watt/kg correlated with standard PSV, even when corrected for age and BMI (p < 0.05). No differences emerged in cardiopulmonary fitness between pathological and healthy patients (4 vs 21) identified using the standard PSV cut-off. Conversely, the age-adjusted PSV cut-off identified a greater number of patients as pathological (18 vs 7), presenting a significantly lower cardiopulmonary fitness, exercise capacity and efficiency when compared to patients with normal age-adjusted PSV (all p < 0.05).

CONCLUSION

Data showed an age and BMI independent association between vascular disfunction of cavernous artery and cardiopulmonary fitness, a known solid predictor of all-cause and disease-specific mortality. Moreover, the age-adjusted PSV better identified a subgroup of patients with vascular ED presenting impaired cardiorespiratory fitness and thus increased cardiovascular risk. De Rocco Ponce M, Vecchiato M, Neunhaeuserer D, et al. Association Between Penile Color Doppler Ultrasonography and Cardiorespiratory Fitness in Patients With Vascular Erectile Dysfunction. Sex Med 2021;9:100347.

The Interplay of the Global Atherosclerotic Cardiovascular Disease Risk Scoring and Cardiorespiratory Fitness for the Prediction of All-Cause Mortality and Myocardial Infarction: The Henry Ford ExercIse Testing Project (The FIT Project)

Cardiorespiratory fitness (CRF) is inversely associated with atherosclerotic cardiovascular disease (ASCVD) risk. It is unclear whether the prognostic value of CRF differs by baseline estimated ASCVD risk. We studied a retrospective cohort of patients without known heart failure or myocardial infarction (MI) who underwent treadmill stress testing. CRF was measured by metabolic equivalents of task (METs) and ASCVD risk was calculated using the Pooled Cohorts Equations. Multivariable-adjusted Cox regressions analyses examined the association between METs and incident all-cause mortality and MI outcomes stratified by baseline ASCVD risk. The C-index evaluated risk discrimination while net reclassification improvement evaluated reclassification with CRF added to the ASCVD risk score. Our study population consisted of 57,999 patients of mean age 53 (13) years, 49% women, 64% white, 29% black. Over a median follow-up 11 years (interquartile range 8 to 14 years) there were 6,670 (11%) deaths, while there were 1,757 (3.0%) MIs over a median follow-up of 6 years (interquartile range 3 to 8 years). Among patients with ASCVD risk ≥20%, those with METs ≥12 had a 77% lower risk of all-cause mortality (Hazard ratio 0.23 95% confidence interval = 0.20, 0.27) and 67% lower risk of MI (Hazard ratio 0.33 95% confidence interval = 0.24, 0.46) compared to METs <6. Similar results were obtained for those with ASCVD risk <5%. Addition of METs to ASCVD risk score improved the C-statistic from 0.778 to 0.798 for all-cause mortality and 0.726 to 0.733 for MI (both p <0.001). Addition of METs to ASCVD risk score significantly reclassified risk of all-cause mortality (p <0.001) but not MI (p = 0.052). In conclusion, CRF is inversely associated with risk of all-cause mortality and MI at all levels of ASCVD risk, and provides incremental risk discrimination and reclassification beyond the ASCVD risk score.

Association Between Cardiorespiratory Fitness and Risk of Type 2 Diabetes: A Meta-Analysis

OBJECTIVE

This meta-analysis aimed to (1) quantify the association of cardiorespiratory fitness (CRF) with type 2 diabetes risk in the general population and statin users and (2) investigate the joint effects of CRF and fatness with type 2 diabetes risk.

METHODS

Databases were searched for cohort studies reporting the association between CRF and type 2 diabetes risk. Summary hazard ratios (HRs) were obtained using random-effects models.

RESULTS

Fifteen studies were included. The HRs of type 2 diabetes for every 1-metabolic equivalent increase in CRF were 0.90 (95% CI: 0.86-0.94) for the general population and 0.92 (95% CI: 0.87-0.97) for statin users, and the HRs were linearly shaped (both P_nonlinearity  > 0.40). Compared with the nonstatin cohort, there was an increased risk of type 2 diabetes in statin users with the lowest and moderate CRF categories, but this was not present in the highest CRF category. The HR of type 2 diabetes for overweight/obesity-fit category versus normal weight-fit category was larger than that of the normal weight-unfit category versus the normal weight-fit category (P_interaction   = 0.004).

CONCLUSIONS

There was an inverse and dose-dependent association between CRF and type 2 diabetes risk. High CRF may eliminate the diabetogenic effect from statins, yet decreased body weight index seems superior in preventing type 2 diabetes.

Cardiorespiratory Fitness and Cardiovascular Disease Prevention: an Update

PURPOSE OF REVIEW

Cardiovascular diseases account for nearly one third of all deaths globally. Improving exercise capacity and cardiorespiratory fitness (CRF) has been an important target to reduce cardiovascular events. In addition, the American Heart Association defined decreased physical activity as the fourth risk factor for coronary artery disease. Multiple large cohort studies have evaluated the impact of CRF on outcomes. In this review, we will discuss the role of CRF in reducing cardiovascular morbidity and mortality.

RECENT FINDINGS

Recent data suggest that CRF has an important role in reducing not only cardiovascular and all-cause mortality, but also incident myocardial infarction, hypertension, diabetes, atrial fibrillation, heart failure, and stroke. Most recently, its role in cancer prevention started to emerge. CRF protective effects have also been seen in patients with prior comorbidities like prior coronary artery disease, heart failure, depression, end-stage renal disease, and stroke. The prognostic value of CRF has been demonstrated in various patient populations and cardiovascular conditions. Higher CRF is associated with improved survival and decreased incidence of cardiovascular diseases (CVD) and other comorbidities including hypertension, diabetes, heart failure, and atrial fibrillation.

Sex and Gender Differences in Prevention of Type 2 Diabetes

Lifestyle intervention programs are effective in the prevention of type 2 diabetes mellitus (T2DM) in high risk populations. However, most studies only give limited information about the influence of sex and/or gender effectiveness of these interventions. So far, similar outcome was reported for diabetes progression and weight loss. Nevertheless, long-term data on cardiovascular outcome are sparse but favoring women regarding all-cause and cardiovascular mortality. In both men and women, sex hormone imbalances and reproductive disorders are associated with a higher risk of T2DM development. Diabetes prevention approaches are reported for polycystic ovary syndrome, gestational diabetes mellitus, and erectile dysfunction and are presented in this review. In the surgical treatment options for morbid obese patients, sex and gender differences are present. Choices and preferences of adherence to lifestyle and pharmacological interventions, expectations, treatment effects, and complications are influenced by sex or gender. In general, bariatric surgery is performed more often in women seeking medical/surgical help to lose weight. Men are older and have higher comorbidities and mortality rates and worse follow-up outcome after bariatric surgery. A more gender-sensitive clinical approach, as well as consideration of ethnicity may improve quality of life and increase health and life expectancy in men and women with a high risk for subsequent progression to T2DM.

Vascular Erectile Dysfunction and Subclinical Cardiovascular Disease

PURPOSE OF REVIEW

We review the recent literature on the hypothesized temporal relationship between subclinical cardiovascular disease (CVD), vascular erectile dysfunction (ED), and clinical CVD. In addition, we combine emerging research with expert consensus guidelines such as The Princeton Consensus III to provide a preventive cardiologist's perspective toward an ideal approach to evaluating and managing CVD and ED risk in patients.

RECENT FINDINGS

Development of ED was found to occur during the progression from subclinical CVD to clinical CVD. A strong association was observed between subclinical CVD as assessed by coronary artery calcium (CAC) and carotid plaque and subsequent ED, providing evidence for the role of subclinical CVD in predicting ED. ED is also identified as a substantial independent risk factor for overt clinical CVD, and ED symptoms may precede CVD symptoms by 2-3 years.

SUMMARY

Given the body of evidence on the relationship between subclinical CVD, ED, and clinical CVD we recommend that all men with vascular ED should undergo cardiovascular risk assessment. We further recommend using CAC scores for advanced risk assessment in patients at low-intermediate to intermediate risk (5-20% CVD risk), with risk driving subsequent lifestyle and pharmacologic treatment decisions.

Prognostic value of exercise capacity among men undergoing pharmacologic treatment for erectile dysfunction: The FIT Project

BACKGROUND

Vascular erectile dysfunction (ED) has been identified as a potentially useful risk factor for predicting future cardiovascular events, particularly in younger men. Because these men typically score more favorably on traditional cardiovascular disease risk assessment tools, there exists a gap in knowledge for how to most appropriately identify those men who would benefit from more aggressive treatments. To date, no studies have examined the impact of fitness on cardiovascular outcomes in men with ED. This study sought to examine the prognostic impact of maximal exercise capacity on cardiovascular-related outcomes in men ages 40 to 60 years being treated for ED.

HYPOTHESIS

We hypothesized that there would be an independent association between higher baseline fitness level and lower cardiovascular events.

METHODS

We analyzed 1152 men with pharmacy claims file-confirmed active pharmacologic treatment for ED from the Henry Ford Exercise Testing (FIT) Project (1991-2009). All patients were free of coronary heart disease and heart failure, and underwent clinician-referred exercise stress testing, with fitness measured in metabolic equivalents of task (METs). Multivariable Cox proportional hazard models adjusted for traditional cardiovascular risk factors were used to study the association between fitness and all-cause mortality, major adverse cardiovascular events (MACE) (defined as myocardial infarction or revascularization), and incident type 2 diabetes mellitus.

RESULTS

The mean age of the population was 53 years, with 39% African Americans. In multivariable analysis, each 1 MET of fitness was associated with a 16% lower risk of death (hazard ratio [HR]: 0.84, 95% confidence interval [CI]: 0.76-0.94, P = 0.002), and a nonsignificant reduction in MACE (HR: 0.89, 95% CI: 0.79-1.003, P = 0.048), and incident diabetes (HR: 0.92, 95% CI: 0.85-1.01, P = 0.129).

CONCLUSIONS

Higher baseline fitness is associated with improved cardiovascular prognosis in a population of middle-aged men treated for ED.