Erectile Dysfunction Decreases Risk of Cardiovascular Events in Patients With Rheumatoid Arthritis

When compared with patients with rheumatoid arthritis (RA) alone, those with RA and erectile dysfunction (ED) had a decreased risk of certain cardiovascular (CV) events such as heart failure, myocardial infarction, and death, according to a study published in the Journal of Rheumatology.¹ Additionally, the rate of ED was not significantly increased in patients with RA.

Developing ED is generally an indicator that a patient will eventually have CV disease (2-3 years before CV symptoms and 2-5 years before CV events). When compared with the general population, patients with RA have an increased risk of developing CV disease, due in part to inflammation, which is responsible for 30-50% of deaths in this patient population. Common CV-related conditions include coronary artery disease, myocardial infarction (MI), heart failure (HF), cerebrovascular events, venous thromboembolism, and sudden death.

“Due to the association of ED with CV events in the general population, we hypothesized that men with RA would have an increased rate of most CV events when also diagnosed with ED,” stated investigators. “Interestingly, this was not the case. Most CV events were not statistically associated with ED diagnosis, potentially indicating that risk from ED and RA are redundant. Peripheral arterial disease was the only CV condition that was increased by the presence of ED, with potential interaction between RA and ED diagnosis.”

In this retrospective study, a total of 260 men with RA from Olmsted County, Minnesota, as well as an age-matched male cohort (n = 260), were analyzed using the Rochester Epidemiology Project (REP). Eligible patients were aged ≥ 18 years and were diagnosed with RA between January 1, 1980, and December 31, 2007. Patients needed to meet at least 4 of the 7 American College of Rheumatology (ACR) 1987 classification criteria for RA.

Data collected from the medical records included ED diagnosis information, risk factors for ED (such as alcohol concerns, thyroid disease, depression, anxiety, penile or spinal trauma, and pelvic radiation), treatments for ED, and medications that may impact ED (aspirin, antihypertensives, antidepressants, and antiandrogens). CV disease collected included MI, revascularization procedures, angina, and HF. Smoking status and BMI were obtained, as well as noncardiac vascular diseases, including venous thromboembolism, cerebrovascular events, and peripheral arterial events.

Prevalence of ED at incidence/index rate (HR 0.80, 95% CI 0.55–1.16), as well as baseline CV characteristics and predisposing factors were similar in both cohorts. Throughout the study, men aged < 50 years (P = 0.74; Table 2) and men aged ≥ 50 years (P = 0.17) had no significant difference in ED diagnosis rates. For those with an ED diagnosis, both the comparator group and patients with RA were treated in a similar manner.

Surprisingly, patients with RA and ED had a significantly decreased rate of myocardial infarction (HR 0.26, 95% CI 0.07–0.90), heart failure (HR 0.49, 95% CI 0.25–0.94), and death (HR 0.56; 95% CI 0.36–0.87). Investigators associated those taking phosphodiesterase-5 (PDE5) inhibitors with a decreased risk of death and certain CV diagnoses.

Men with RA and ED were shown to have an increase in peripheral arterial disease (HR 2.22, 95% CI 0.98–5.03), however, it did not reach a level of statistical significance.

The study was hindered by a demographic composition that was disproportionately White as well as the limited sample size, thus limiting generalizability. As it was a retrospective study, the availability of medical record information may have created an unintentional bias. As investigators believed frequent underdiagnosis of ED was an issue, they would like future studies to ascertain an accurate ED risk.

However, strengths include the thorough medical data provided by REP, which allows for a population-based assessment and long-term longitudinal follow-up over decades. Access to medical records confirmed International Classification of Diseases (ICD) code-based physician diagnosis. Lastly, the ability to age-match males from the general population secured a geographically based comparator cohort.

“The incidence of ED in patients with RA is similar to that of age-matched comparators. Although ED did not affect the overall rate of CV events in RA, it was associated with an increased risk of peripheral arterial disease and a decreased risk of MI and HF,” concluded investigators. “While these trends require further study, they may be explained by common pathologic mechanisms, healthcare-related confounding variables, or the use of vasoactive pharmacologic therapy for ED.”

Reference:

Wilton KM, Achenbach SJ, Davis JM 3rd, Myasoedova E, Matteson EL, Crowson CS. Erectile Dysfunction and Cardiovascular Risk in Men with Rheumatoid Arthritis: A Population- Based Cohort Study [published online ahead of print, 2021 Jan 15]. J Rheumatol. 2021;jrheum.201226. doi:10.3899/jrheum.201226