Previous studies have found that erectile dysfunction (ED) and cardiovascular disease (CVD) share common risk factors, but the relationship between CVD and ED has been inconclusive. Professor Vlachopoulos of Athens Medical School, Italy, analyzed the pathophysiological link between CVD and ED in the literature and concluded that ED is an early symptom of CVD. The paper will be published in the May issue of EUROPEAN UROLOGY. The systematic evaluation included 41 publications from Medline, Embase and Web of Science between January 2005 and May 2013, including prospective studies, large preclinical studies and retrospective analyses. The results suggest that ED and CVD share common risk factors, and that risk factors for CVD such as age, body mass index (BMI), cholesterol, triglyceride smoking, hypertension, and smoking are significantly associated with ED. In addition, diabetes increases the risk of both CVD and sexual dysfunction, with endothelial cell dysfunction and penile atherosclerosis being common features of both. Autonomic hyperfunction and altered hormone levels may be more complex pathophysiological mechanisms. 2. ED is a predictor of CVD and coronary heart disease. High validity questionnaires (e.g., International Inventory of Erectile Function, IIEF) can better assess ED and its severity, thus improving the ability to predict the risk of cardiovascular events. 3. The severity of ED correlates with the degree of coronary artery disease. Patients with reduced or severely reduced erectile hardness were 1.6 and 2.6 times more likely to have CAD compared with normal penile hardness, respectively. In addition, the severity of ED was associated with the extensiveness of CVD vasculopathy and coronary artery calcification. The pathophysiological link between ED and CAD is as follows: (1) Arterial diameter can largely explain the relationship between ED and CAD, but ED is not only due to penile atherosclerosis, but may be related to other factors such as endothelial cell dysfunction and autonomic hyperactivity. (2) Endothelial cell dysfunction has an important role in the pathology of ED and CAD, and chronic inflammation, which affects endothelial cell function and may contribute to a prothrombotic state, may be a link between ED and CAD. (3) Androgen levels play an important role in the homeostasis of the vascular tissue of the penile arteries and cardiovascular system, and low androgen levels may explain the complex relationship between ED and CAD. The relationship between endothelial cell dysfunction, low-grade chronic inflammation, and atherosclerosis in the pathogenesis of ED and CAD. 5. Clinical application (1) ED is a marker of latent cardiovascular disease. (2) General practitioners, urologists, and cardiologists should screen patients with ED for CVD to recommend lifestyle changes or to determine which patients could benefit from further cardiovascular evaluation. Patients with organic ED who are unsure of the presence of CVD should be evaluated for: (1) history, including age, routine cardiovascular risk factors, and lifestyle; (2) physical examination, noting blood pressure, waist circumference, BMI, fundic artery changes, cardiac auscultation, carotid murmur, and palpation of the femoral and pedal arteries; (3) severity and persistence of ED; (4) resting electrocardiogram; (5) fasting glucose level; (6) serum (6) serum creatinine level and albumin/creatinine ratio; (7) total testosterone level; and (8) lipid level (total cholesterol, LDL, HDL, and triglyceride levels). Further assessment includes: exercise capacity and exercise stress test. (3) Testosterone replacement therapy may improve ED symptoms and be beneficial to the cardiovascular system, but the current study has limitations. (4) 5-phosphodiesterase inhibitors may have a protective effect on cardiovascular disease risk in patients with ED, but this conclusion needs to be further established in large randomized controlled clinical trials. Management of patients with ED, especially those with known cardiovascular disease (as recommended by the Princeton III consensus). ED and CVD: Key clinical practice points ED is a common disease, especially in older patients; ED and CVD share common risk factors; ED and CVD share a common pathophysiologic background; ED is quite common in patients with CAD; ED can be a marker for general vascular disease; ED usually presents 2-5 years earlier than CVD; ED is predictive of cardiovascular events and ED is a predictor of cardiovascular events and mortality; ED patients at intermediate risk should undergo further cardiovascular risk assessment; and treatment of ED is expected to reduce the risk of CVD. The study concludes that CVD and ED are different manifestations of the same systemic disease, and that androgens, chronic inflammation, endothelial cell damage, and autonomic hyperfunction are the pathophysiological basis for linking the two. Therefore, patients with ED should undergo detailed cardiovascular evaluation and treatment to reduce the risk of CVD.