Sexual function assessment should be incorporated into the system of cardiovascular risk assessment for all men. This is the opinion of Dr. Ajay Nehra (Professor and Associate Chief of the Department of Men’s Urologic Health Surgery at La Sierra University Medical Center in Chicago) in his report as moderator of the Princeton Expert Consensus. The expert consensus brings together the opinions of 22 international, multi-specialty researchers. Erectile dysfunction (ED) is a red flag for future cardiovascular disease or cardiovascular death in men younger than 55 years of age. In some patients, the time window between the onset of ED and a cardiovascular event is between two and five years. “Any man with ED should be considered at higher cardiovascular risk until he can undergo a progressive workup.” Nehra said, “ED is commonly associated with some silent cardiovascular disease without symptoms; additionally it is a good entry point for cardiovascular disease risk reduction.” The expert consensus recommends that male patients older than 30 years with ED should undergo a comprehensive, non-invasive cardiovascular disease evaluation. Because this expert consensus concluded that all men older than 30 years with ED are at elevated risk for cardiovascular disease, a comprehensive non-invasive examination should be performed, with invasive cardiovascular disease screening recommended if indicated. They found that young men with ED had double the risk of cardiovascular disease compared to men without ED. The risk of cardiovascular disease was highest among young men. Although controversial, the consensus also recommends testing testosterone levels in all patients diagnosed with organic ED, as recent studies have linked low testosterone levels to ED, cardiovascular disease and cardiovascular mortality. “Testosterone level testing should be performed routinely. Men with low testosterone levels versus 230 have higher all-cause mortality and cardiovascular mortality,” Dr. Nehra said. In a population study that included 500 patients, the low testosterone level population, mortality was higher. These recommendations for ED and CVD management have emerged since the 2010 Princeton III Cardiometabolic Risk and Sexual Health Conference. Published in the August 2012 issue of the Mayo Clinic Record. The purpose of the Princeton III conference was to seek ways to optimize sexual function in men with CVD while maintaining their cardiovascular health. This conference updates the findings from the Princeton I (2000) and II (2005) conferences. ”This conference looked at the role of vascular erectile dysfunction in assessing the predictive role of cardiovascular disease risk endpoints in male patients of all ages. It was objectively concluded that young men with ED and without cardiovascular disease should undergo a basic cardiovascular risk assessment.” The expert consensus expands the scope of the 2010 ACA/AHA guidelines for assessing asymptomatic recognition of cardiovascular disease risk. That ACA/AHA guideline did not address men with ED. Even in some long-term observational studies, such as the well-known Framinghan Heart Study, there are very limited data involving men under the age of 40. “The relationship between ED and cardiovascular disease risk has been carefully considered by experts for a long time,” Nehra said, “and recent data and publications, support the existence of a link between the two.” There is growing scientific evidence that ED is a characteristic precursor to cardiovascular disease in men under 40 years of age. One study showed that men aged 40 to 49 years with ED were more than 50 percent more likely to develop new-onset coronary artery disease than men of the same age without ED. Based on this evidence, the consensus recommendation is that cardiovascular evaluation includes assessment of important risk predictors such as specific blood and urine tests, patient past and family history, and assessment of lifestyle. These assessments will help stratify patients by cardiovascular risk and guide further evaluation and treatment. “This means that the physician who sees a patient for ED can play an important role in helping to monitor and reduce the patient’s cardiovascular risk, even if the patient has no other symptoms.” Nehra said. The new recommendations also emphasize the use of exercise capacity assessments prior to treating ED patients to confirm that each patient’s cardiovascular fitness level meets the physical requirements for sex, especially for those considered at high risk for cardiovascular disease. The consensus also encouraged an integrated approach to the management of male sexual function and cardiovascular risk through the triad of endocrinology, urology, and cardiovascular medicine. The Princeton III expert meeting also strongly urged physicians to pursue ED symptoms in men over 30 years of age with cardiovascular disease risk factors. “Determining the presence of ED, especially in patients older than 60 years, is an important first step in cardiovascular disease detection and reduction.” The expert consensus reached these conclusions.