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Erectile dysfunction (ED) is the inability to achieveand/or maintain an erection sufcient to permitsatisfactory sexual intercourse [1]. ED is nowadaysa common condition affecting approximately 5–20%of adult men; ED has a considerable effect on thequality of life not only of the patients themselves, butalso of their spouses/family [2–4]. This Editorialdiscusses ED as a manifestation/warning sign ofclinically silent cardiovascular disease. It does notdiscuss ED due to other causes (for instance drugs,depression, etc).A direct association between ED with cardiovas-cular disease has been supported [2–6]. For example,almost one in two stroke patients report some degreeof ED, which is demonstrated as a diminished post-stroke libido and sexual dysfunction compared withbefore the episode [3, 7]. A recent study showed thatstroke patients had a [3-fold increased risk ofreporting ED compared with nonstroke patients (oddsratio [OR], 3.30; 95% condence interval [CI], 1.22–8.88) [8]. ED is thus an important problem in strokepatients with considerable psychosocial conse-quences [9].Another study including 690 male patients whohad been referred for stress testing, without diag-nosed peripheral arterial disease (PAD) showed thatED is a marker of previously undiagnosed PAD [10].ED was present in 45%, while PAD was present in23% of the patient group. More men with ED hadconcomitant PAD compared with patients withoutED (32 vs. 16%, respectively; P\0.01). On multi-variate logistic regression analysis, ED was anindependent predictor of PAD (OR, 1.97; 95% CI,1.32–2.94; P = 0.002). Therefore, ED may identifymen who would benet from screening using theankle–brachial pressure index [10].The prevalence of carotid and/or lower limb arteryatherosclerosis was investigated in patients with ED[11]. The incidence of simultaneous penile arterialinsufciency and carotid and/or lower limb arteryabnormalities was higher compared with that foundin patients with ED of nonarterial organic or

Erectile dysfunction: a warning sign of silent vascular disease