Peripheral Atherosclerosis in Patients With Erectile Dysfunction: A

Population-Based Study
Carlos Lahoz, MD,1 Jose M. Mostaza, MD,1 Miguel A. Salinero-Fort, MD,2 Francisca García-Iglesias, MD,1
Teresa González-Alegre, MD,1 Eva Estirado, MD,1 Fernando Laguna, MD,1 Carmen de Burgos-Lunar, MD,3
Vanesa Sánchez-Arroyo, MD,4 Concesa Sabín, MD,4 Silvia López, MD,4 Víctor Cornejo-Del-Río, MD,4
Pedro Patrón, MD,4 Pedro Fernández-García, MD,4 Belén Fernández-Puntero, MD,4 David Vicent, MD,4 and
Luis Montesano-Sanchez, MD,4 the SPREDIA-2 Group

ABSTRACT

Introduction: The presence of erectile dysfunction (ED) could be a warning of vascular disease in different
arterial territories.
Aim: The aim of this study was to investigate the association between ED and the presence of atherosclerosis in 2
different vascular beds: carotid and lower limbs.
Methods: A total of 614 volunteers between 45 and 74 years of age (mean age 61.0 years) were randomly
selected from the general population. ED was assessed using the International Index of Erectile Function (IIEF-5).
Ankle-brachial index (ABI) measurement and carotid atherosclerosis were evaluated by echo-Doppler.
Main Outcome Measures: Mean carotid intima-media thickness (IMT), prevalence of carotid plaques, mean
ABI, and prevalence of ABI < 0.9 were the main outcome measures.
Results: ED was present in 373 subjects (59.7%). Mean carotid IMT was significantly higher in men with ED
(0.762 ± 0.151 mm vs 0.718 ± 0.114 mm, P < .001). Also the global prevalence of carotid plaques was more
frequent in men with ED (63.8% vs 44.8%, P < .001), even after adjusting by age, cardiovascular risk factors,
and ongoing treatment (P ¼ .039). Both the IMT and the prevalence of carotid plaques increased significantly
with ED severity (P trend .004 and <.001, respectively). There were no significant differences between groups
neither in mean ABI nor in the prevalence of subjects with ABI < 0.9. However, there was a trend to a lower ABI
and a higher prevalence of ABI < 0.9 with increasing ED severity.
Conclusion: In the general population, the presence of ED identifies subjects with higher atherosclerosis burden
in carotid arteries but not in the lower extremities.
J Sex Med 2016;13:63e69. Copyright
2016, International Society for Sexual Medicine. Published by Elsevier Inc.
All rights reserved.
Key Words: Ankle-Brachial Index; Carotid Artery Plaque; Erectile Dysfunction; Intima-Media Thickness

INTRODUCTION 20e39 years to 70% in men aged 70 years and older.1 The
Erectile dysfunction (ED) is defined as the persistent inability majority of cases have an organic etiology, most commonly
to attain or maintain satisfactory erection for intercourse. Its vascular disease. Cardiovascular risk factors such as dyslipidemia,
prevalence increases with age, ranging from 5% in men aged hypertension, obesity, and smoking have been shown to increase
the risk of ED.2
Several meta-analyses have shown that ED significantly in-
Received September 30, 2015. Accepted November 30, 2015.
creases the risk of cardiovascular disease (CVD), coronary heart
1
Atherosclerosis Unit, Internal Medicine Department, Hospital Carlos III, disease (CHD), stroke, and all-cause mortality.3e5 CVD and
Madrid, Spain;
2
ED share etiology and pathophysiology, and the degree of ED
Gerencia Adjunta de Planificación y Calidad, Atención Primaria, Servicio
Madrileño de Salud, Madrid, Spain;
correlates with severity of CVD.6 ED often precedes the
3
Servicio de Medicina Preventiva, Hospital Universitario La Paz, Spain;
appearance of clinical CVD,7 probably because the penile artery
4 has a smaller diameter than coronary arteries and an equally
Hospital Carlos III, Madrid, Spain
sized atherosclerotic plaque developed in the smaller penile
Copyright ª 2016, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved. arteries would more likely compromise flow than if the plaque
http://dx.doi.org/10.1016/j.jsxm.2015.11.011 developed in the larger coronary arteries.6 Therefore, the

J Sex Med 2016;13:63e69 63

64
presence of ED could be a warning of vascular disease in
different arterial beds.7
Measurement of the ankle-brachial index (ABI) is a simple,
low-cost, and accurate test for the diagnosis of peripheral artery
disease (PAD). The presence of an ABI < 0.9 is accepted as a
highly sensitive and specific diagnostic marker of PAD when
compared with arteriography, even in patients with no clinical
evidence of the disease.8 A low ABI has been associated with an
increased risk of cardiovascular morbidity and mortality.9,10
Only a few studies have evaluated the association between ED
and PAD, and this has been usually done in special populations,
such as diabetics11,12 or subjects with high cardiovascular risk.13
No previous studies of this relationship have been done in the
general population.
B-mode ultrasound of carotid arteries provides measures of
intima-media thickness (IMT) and plaque, both widely used as
surrogate measures of CVD. Carotid IMT and plaque burden
have been shown to be independent predictors of future car-
diovascular risk.14,15 The relationship between carotid athero-
sclerosis and ED has been investigated in small studies with
contradictory results.16e18 Finally, few studies have simulta-
neously evaluated the involvement of both vascular beds in pa-
tients with ED,20,21 but never in a population-based study.
The aim of this study was to investigate the association be-
tween ED and the presence of atherosclerosis in 2 different
vascular beds, carotid and lower limbs, measured by B-mode
carotid ultrasound and ABI, respectively, in men between 45 and
74 years randomly selected from the general population.
MATERIAL AND METHODS
The characteristics of the Screening PRE-diabetes and type 2
DIAbetes (SPREDIA-2) study have already been described.22 In
short, the SPREDIA-2 study is a population-based prospective
cohort study with baseline screening, in the region of Madrid
(Spain). A random sample of urban subjects, between 45 and 74
years living in the northwest metropolitan area of Madrid was
selected for the study. Women, subjects with severe chronic or
terminal illnesses, institutionalized subjects, or those chronically
treated with steroids or antipsychotic drugs were excluded.
Participants were scheduled in the outpatient clinic of the
Carlos III Hospital after an overnight fast. Upon arrival, and after
signing a consent form, a fasting blood analysis was obtained for
measuring the blood levels of glucose, creatinine, HbA1c, lipids,
and lipoproteins. Sociodemographic variables, family history of
prevalent diseases, cardiovascular risk factors (smoking habit,
hypertension, diabetes, hypercholesterolemia), clinical history of
CVD, comorbidities, and current treatments were recorded for
all individuals. Participants were considered as hypertensive when
the arterial pressure was  140/90 mm Hg or were receiving
antihypertensive treatment. Hypercholesterolemia was defined
has having LDL-cholesterol  100 mg/dL (2.57 mmol/L) and/or
receiving hypolipidemic medication. The smoking habit included
Lahoz et al
all who had consumed tobacco over the previous month.
A diabetes diagnosis was established when baseline glucose
was  7 mmol/L (126 mg/dL) on 2 different occasions, or if the
patient was receiving oral hypoglycemic drugs, or insulin. CVD
included documented history of coronary heart disease (acute
myocardial infarction, angina, coronary revascularization proce-
dure), ischemic or hemorrhagic stroke, and peripheral arterial
disease. All participants had a physical examination with deter-
mination of height, weight, waist circumference (midway between
lowest rib and the iliac crest), and blood pressure.
ED Assessment
ED was assessed using the IIEF-5,23 Which is designed to be a
self-administered measure of ED. The IIEF score ranges from 5
to 25 points, in which a descending score indicates worsening of
ED. Erectile dysfunction was classified as normal, mild, mild-
moderate, moderate, and severe for IIEFs of  22, 17e21,
12e16, 8e11, and  7, respectively.
Laboratory Methods
Cholesterol and triglycerides were determined by enzymatic
assays. Low-density lipoprotein cholesterol (LDL-cholesterol)
was calculated according to the Friedewald formula (LDL-
cholesterol ¼ total cholesterol  ([high-density lipoprotein
cholesterol (HDL-cholesterol) þ triglycerides/5]) in subjects
with triglycerides below 400 mg/dL. HDL-cholesterol was
measured after precipitation of apo-B lipoproteins. Glucose was
measured by the glucose oxidase method. HbA1c was measured
by a high-performance liquid chromatography (HPLC) method.
ABI Determination
The ABI measurements were performed with a bidirectional
portable echo-Doppler of 8 MHz (Minidoppler HADECO ES-
100, Kawasaki, Japan) and a calibrated sphygmomanometer. The
systolic blood pressure (SBP) was measured in the posterior tibial
and pedal arteries of both lower limbs and the brachial artery of
both upper limbs. The value of the ABI for each limb was
calculated dividing the greater.
SBP obtained in each limb by the SBP of whichever was the
higher in the upper limbs. The lowest value obtained was
considered the ABI for that individual.
IMT and Carotid Plaque Assessment
An echo-Doppler of both carotids was performed with a 7.5-
MHz probe (Sonosite Micromaxx Ultrasound, Sonosite Inc,
Bothell, WA, USA). Patients lay in the supine position with the
neck rotated to the opposite site of the examination. One
centimeter images were obtained from the distal wall of the
common carotid artery proximal to the bifurcation, in 3 different
angles views. IMT was obtained with an automated software
(Sonosite, Sonocalc IMT Software, Sonosite Inc), and the overall
mean IMT values for each of the 6 segments analyzed (3 angles
J Sex Med 2016;13:63e69
Peripheral Atherosclerosis and Erectile Dysfunction
in 2 territories), was calculated. IMT values for the 3 different
projections and for right and left carotid arteries were averaged to
obtain the mean-CCA-IMT. Carotid plaques were defined as a
local thickening of the intima > 1 mm or a thickening of > 50%
of the surrounding IMT value.
Statistical Analysis
The quantitative variables are presented as means with stan-
dard deviation and the qualitative variables are presented as
percentages. To check for normality of distribution of quanti-
tative variables the Kolmogorov-Smirnof test was applied. The
variables that were not normally distributed, such as triglycerides,
needed to be log-transformed before applying the statistical an-
alyses. For clearer presentation, the original nontransformed
values are presented in the table. Unpaired 2-sided Student t tests
were used for comparison of means of normally distributed pa-
rameters and comparisons between the qualitative variables were
done using the c2 test. Logistic regression analyses were per-
formed to evaluate the independent association of ABI, ABI <
0.9, IMT, and the presence of carotid plaques to ED. Inde-
pendent variables were those that, in the bivariate analysis,
showed significance levels of P < .10, as well as those that were
considered clinically important.
Statistical processing of the data was performed with SPSS
v.19 software (IBM Inc, Armonk, NY, USA).
Ethical Considerations
The study protocol has been approved by the Research Ethics
Committee of the Carlos III Hospital in Madrid. The study will
comply with the International Guidelines for Ethical Review of
Epidemiological Studies (Geneva, 1991). All patients will sign an
informed consent form. Finally, to guarantee the quality of
reporting of the study, the protocol has been developed ac-
cording to the STARD (Standards for Reporting of Diagnostic
Accuracy) statement.
RESULTS
A total of 1592 subjects agreed to participate in the study, 684
(42.9%) of whom were male. We excluded 34 participants who
did not complete the IIEF-5 and 36 who took phosphodiesterase
type 5 inhibitors, leaving a final study group of 614 subjects.
Seven subjects with ABI > 1.5 or incompressible were excluded
for ABI calculations. Carotid studies were not performed in 37
participants. Overall, 59.7% (n ¼ 373) of men in the study
group were found to have ED, mild ED was found in 199
(32.4%) of participants, mild-moderate ED in 94 (15.3%),
moderate ED in 44 (7.2%), and severe ED in 36 (5.9%).Base-
line patient characteristics of those with and without ED are
listed in Table 1. Men with ED were older and more frequently
had diabetes, hypertension, and CVD. The ED group had also
higher levels of glucose and hemoglobin A1C, SBP, and lower
levels of total and LDL-cholesterol. The group with ED had a
J Sex Med 2016;13:63e69
65
higher percentage of subjects treated with statins, antiplatelet
drugs, angiotensin-renin system blockers (ARBs), and oral anti-
diabetic agents. After adjusting for age, the association between
ED and hypertension, systolic blood pressure, and ARBs lost its
statistical significance.
Mean carotid IMT was significantly higher in men with ED
(0.762 ± 0.151 mm vs 0.718 ± 0.114 mm, P < .001) (Table 2).
Also, the global prevalence of carotid plaques was more frequent
in men with ED (63.8% vs 44.8%, P < .001). Mean ABI was
1.16 ± 0.14 in ED men compared with 1.18 ± 04 in men
without ED. In total, 4.3% of ED subjects had an ABI lower
than 0.9, vs 2.5% in the normal population. There were no
significant differences between groups either in mean ABI or in
the prevalence of subjects with ABI < 0.9. There were no sig-
nificant changes after adjusting for age (Table 2).
Both the IMT and the prevalence of carotid plaques increased
significantly with ED severity (P trend ¼ .004 and < .001,
respectively) (Table 3). In men with ED there was also a stepwise
decrease in mean ABI (P trend ¼ .004) and a stepwise increase in
prevalence of ABI < 0.90 (P trend ¼ .014) (Table 4). In the
logistic regression analysis the association between the prevalence
of carotid plaques and ED remained statistically significant (OR
1.502 [95% CI 1.022e2.209], P ¼ .039), after adjusting for age,
diabetes, hypertension, smoking, hypercholesterolemia,metabolic
syndrome, CVD, diuretics, statins, ARBs, antiplatelet drugs, and
oral antidiabetic agents. Not so with the association between ED
and the mean IMT that lost its significance in the multivariate
analysis [OR 3.556 (95% CI 0.803e15.763), P ¼ .096].
DISCUSSION
Several studies have assessed the relationship between ED,
PAD, and carotid atherosclerosis in various clinical situations,
but it has not been done in population studies. In our study,
patients with ED had a higher prevalence of carotid plaques and
an increased IMT, although the association with the latter dis-
appeared in the multivariate analysis. Moreover, the presence of
ED was not associated with a lower ABI and the presence of
PAD, defined as an ABI < 0.9.
Our population of men with ED had a higher frequency of
cardiovascular risk factors, a higher prevalence of CVD, and an
increased rate of prescription of CVD medication. Diabetes
mellitus, hypertension, dyslipidemia, obesity, and smoking are
well known risk factors associated with coronary artery disease
and ED.24 Hypertension and diabetes were more prevalent in
ED men. The percentage of current smokers was lower in ED
subjects because there was a greater number of past smokers in
this group. Mean LDL-cholesterol was lower in the ED group,
probably due to the large number of patients on statins,
compared with non-ED subjects (32.7% vs 19.1%).
Several meta-analyses have shown that ED is associated with
CVD and is a strong predictor of future cardiovascular events.3e5
In this study, prevalence of CVD was twice as high in subjects
66 Lahoz et al

Table 1. General Characteristics of the Overall Study Population, and Segregated by the Presence of Erectile Dysfunction
Total Normal ED
Variable N ¼ 614 n ¼ 241 n ¼ 373 P P*

Age, y (SD) 61.0 (6.2) 59.9 (5.9) 62.3 (6.1) <.001 -

Smoking status
Current smoker (%) 18.6 21.2 16.9 .054 .062
Past smoker (%) 49.2 43.2 53.1
Never smoker (%) 32.2 35.7 30.0
Diabetes (%) 13.2 7.5 16.9 < .001 .013
Hypertension (%) 38.9 34.0 42.1 .045 .391
Hypercholesterolemia (%) 47.4 43.6 49.9 .127 .134
CVD (%) 10.8 6.3 13.7 .004 .033
Metabolic syndrome (%) 42.2 38.9 44.3 .189 .363
BMI, kg/m2 (SD) 28.7 (4.0) 28.4 (3.4) 28.8 (4.3) .150 .103
Glucose, mg/dL (SD) 109 (19) 106 (16) 112 (20) < .001 .004
Hemoglobin A1C, % (SD) 5.8 (0.6) 5.7 (0.5) 5.8 (0.6) .001 .013
Total Cholesterol, mg/dL (SD) 197 (38) 203 (35) 193 (39) .003 .016
LDL-cholesterol, mg/dL (SD) 127 (34) 133 (32) 123 (35) .001 .008
HDL-cholesterol, mg/dL (SD) 47 (11) 47 (11) 47 (11) .800 .269
Triglycerides, mg/dL (SD) 114 (69) 114 (74) 114 (65) .998 .378
SBP, mm Hg (SD) 128 (16) 126 (14) 129 (16) .005 .157
DBP, mm Hg (SD) 79 (9) 78 (8) 79 (10) .437 .227
Diuretics (%) 9.5 6.7 9.3 .058 .257
Beta-blockers (%) 10.0 9.2 10.5 .603 .946
ARBs (%) 29.5 24.6 32.7 .031 .417
Statins (%) 27.4 19.1 32.7 < .001 .005
Antiplatelet drugs (%) 12.6 6.3 16.6 < .001 .004
Oral antidiabetic agents (%) 10.9 5.4 14.5 < .001 .014
Values expressed as mean (standard deviation); P ¼ difference between the presence or not of erectile dysfunction; P* ¼ after adjusting for age;
DE ¼ erectile dysfunction; CVD ¼ cardiovascular disease; BMI ¼ body mass index; SBP ¼ systolic blood pressure; DBP ¼ diastolic blood pressure;
ARBs ¼ angiotensin-renin system blockers.

with ED. This higher prevalence and the greater frequency of
risk factors in subjects with ED justify the increased use of an-
tiplatelet drugs, statins, and blockers of the angiotensin-renin
system.
PAD primarily results from atherosclerotic occlusion of the
arteries supplying the lower limbs. The greater the stenosis in the
artery, the lower is the measured ABI value. We did not find
significant differences either in mean ABI or in the prevalence of
ABI < 0.9 between men with and without ED. Severo et al also
found no association between ED and ABI in 114 hypertensive
patients with diabetes.12 However, in the DIVA registry, with a
total of 1366 type 2 diabetic patients, the prevalence of abnormal
ABI was significantly higher in subjects with ED compared to
those patients without ED.11 Otherwise, in high-risk patients
who had been referred for cardiac stress testing, men with ED
had significantly more PAD than men without ED (32% vs
16%, P < .01), and there was a stepwise increase in the preva-
lence of PAD with increasing ED severity.11 We also found a
significant trend to a stepwise decrease in mean ABI and a
stepwise increase in prevalence of ABI < 0.90. Finally, in a
Health Insurance database with a total of 12,825 ED patients,
men with ED were observed to have a 75% increase in risk for
PAD after adjusting by cardiovascular risk factor and medica-
tion.25 The diagnoses of PAD and ED were recorded in the
database with the ICD-9 code. There was no information about
how they arrived at the diagnosis of PAD or whether ABI was
measured, and the sensitivity of the diagnosis of ED is not
known. Therefore, it is possible that the association between ED
and low ABI is only observed in individuals at high cardiovascular
risk or in diabetics with an advanced degree of ED.
Carotid IMT is associated with CVD and is an independent
predictor of stroke and myocardial infarction.15 In our popula-
tion mean carotid IMT was significantly higher in men with ED.
Previous studies have evaluated the relationship between the
carotid IMT and ED. Kaiser et al did not find IMT differences in
subjects with and without ED.19 On the other hand, Bochio et al
evaluated the IMT of common carotid arteries in 270 Italians
with ED. IMT was significantly lower in men with no vascular
risk factors compared to men with them, and correlated with the
severity of ED.18 In another small study, hypertensive patients
with ED had higher common carotid IMT that was indepen-
dently associated with ED in multivariable analysis.17 Finally, in
the largest study, with 799 men (84% with ED), the IIEF
showed a significant negative correlation with max IMT.16

J Sex Med 2016;13:63e69

Peripheral Atherosclerosis and Erectile Dysfunction 67

Table 2. Mean Ankle-Brachial Index (ABI), Prevalence of ABI < 0.90, Mean Carotid Intima-Media Thickness, and Prevalence of Carotid
Plaques Segregated by the Presence of Erectile Dysfunction
Normal ED Total P P*

ABI (SD) 1.18 (0.14) 1.16 (0.14) 1.17 (0.14) .093 .342
ABI < 0.9 (%) (CI 95%) 2.5 (0.3e4.6) 4.3 (2.0e6.4) 3.6 (2.0e5.1) .217 .427
Mean IMT; mm (SD) 0.718 (0.114) 0.762 (0.151) 0.745 (0.139) < .001 .027
Carotid plaques (%) (CI95%) 44.8 (38.3e51.2) 63.8 (58.7e68.8) 56.3 (52.3e60.3) < .001 .002
Mean (standard deviation).
ABI ¼ ankle-brachial index; CI ¼ confidence interval; ED ¼ erectile dysfunction; IMT ¼ intima-media thickness; P ¼ difference between the presence or not
of erectile dysfunction; P* ¼ after adjusting for age.

Measures of plaque burden are generally considered better
predictors of atherosclerotic disease than IMT.26 In our popula-
tion, prevalence of carotid plaques was more frequent in men with
ED and the association between the prevalence of carotid plaques
and ED remained statistically significant after adjusting for car-
diovascular risk factors, CVD, and medication. There is scant
information on the association between ED and carotid plaques.In
a study conducted on 102 patients with ED, there was an
increased presence of plaques in the carotid arteries in subjects
with arterial ED compared with patients without arterial ED
(51.2% vs 10.2%).21 Lee et al did not find a higher prevalence of
plaques in subjects with ED (62.6% vs 57.2%) in a cohort of 799
men, but described a significant increase in the severity of plaque
size in accordance with the severity of ED.16 Finally, Foresta et al
studied the development of peripheral atherosclerosis in 238 ED
patients and 52 controls. The prevalence of total carotid and
femoral plaques was higher in ED patients than in controls.20 We
found no association between ED and ABI < 90, probably due to
the fact that this is a less sensitive method to detect atherosclerosis
in the arteries of the lower limbs and is only able to detect large
plaques that significantly reduce the arterial lumen.
Screening and diagnosing ED could be of great importance for
cardiovascular prevention. The Princeton III Consensus Rec-
ommendations for the Management of Erectile Dysfunction and
Cardiovascular Disease considers all men with ED who are older
than 30 years to be at increased CVD risk. In these subjects, a
thorough noninvasive evaluation (exercise stress testing, carotid
IMT, ABI, etc.) of CVD status is recommended.27 Our results
support carrying out a carotid echo-Doppler in patients with ED
because more than 60% of men with ED had carotid plaques, an
independent predictor of myocardial infarction and stroke,28,29
forcing to an intensive treatment of cardiovascular risk factors.
On the other hand, our results do not recommend determining
the ABI in ED subjects because it would be necessary to perform
24 determinations in order to find 1 abnormal result, except in
subjects with severe ED, who would require only 9 de-
terminations to find an abnormal result. Patients with moderate
or severe ED should receive special attention as they are more
likely to have an important and extensive involvement in
different vascular beds. The intensive intervention of risk factors,
such as high cardiovascular risk subjects, and the search for
subclinical atherosclerosis must be a priority in this
subpopulation.
Our study had a number of limitations. First, this was a cross-
sectional study, with the resulting limitations for establishing
causal relationships. Second, there could be a selection bias
because patients with more comorbidities were less likely to assist
the clinic. Third, we cannot rule out a possible effect of anti-
hypertensive drugs (thiazides, beta-blockers) or statins on erectile
performance in our patients, but it is unlikely that the main

Table 3. Mean Intima-Media Thickness and Prevalence of Carotid Table 4. Mean ABI and Prevalence of ABI < 0.9 According to
Plaques According to Erectile Dysfunction Severity Erectile Dysfunction Severity
Prevalence Prevalence
Mean IMT; of Plaque ABI ABI < 0.9
mean (SD), mm % (CI 95%) mean (SD) % (CI 95%)

No erectile 0.7186 (0.1147) 45.1 (38.6e52.0) No erectile 1.186 (0.148) 2.5 (0.3e4.6)
dysfunction dysfunction
(n ¼ 224) (n ¼ 236)
Mild (n ¼ 188) 0.7571 (0.1456) 61.2 (54.1e68.7) Mild (n ¼ 196) 1.184 (0.131) 2.5 (0.8e5.8)
Mild-Moderate (n ¼ 90) 0.7797 (0.1583) 64.4 (53.9e74.8) Mild-moderate (n ¼ 93) 1.151 (0.143) 5.3 (1.7e11.9)
Moderate (n ¼ 42) 0.7398 (0.1490) 69.0 (52.8e83.7) Moderate (n ¼ 44) 1.142 (0.156) 4.5 (0.5e15.4)
Severe (n ¼ 33) 0.7711 (0.1662) 69.7 (54.7e89.0) Severe (n ¼ 36) 1.134 (0.198) 11.1 (3.1e26.0)
P trend .004 < .001 P trend .004 .014
CI ¼ confidence interval; IMT ¼ intima-media thickness; SD ¼ standard ABI ¼ ankle-brachial index; CI ¼ confidence interval; SD ¼ standard
deviation. deviation.

J Sex Med 2016;13:63e69

68
findings of our study were influenced by treatment, as differences
in the frequency of drug use between the two groups were small.
Moreover, they did not modify the relationship between ED and
carotid atherosclerosis in the multivariate regression analyses.
Nevertheless, this is one of the largest studies of patients with ED
performed to date and is the first population-based study that
simultaneously analyzes 2 different vascular beds, carotid and
lower limbs.
In summary, men with ED between 45 and 74 years taken
from the general population have an increased IMT and a higher
prevalence of carotid plaques, indicating a close correlation be-
tween these 2 parameters and ED severity. We did not find an
association between ED and ABI; however, there is a trend to
lower ABI and a higher prevalence of ABI < 0.9 with increasing
ED severity.
ACKNOWLEDGMENTS
We thank all participants of the SPREDIA-2 Group: Concepción
Aguilera Linde (Cs. Ciudad Periodistas), Alvaro R Aguirre De
Carcer Escolano (Cs. La Ventilla), Patricio Alonso Sacristán
(Cs. Ciudad Periodistas), M Jesús Alvarez Otero (Cs. Dr Cas-
troviejo), Paloma Arribas Pérez (Cs. Santa Hortensia), María Luisa
Asensio Ruiz (Cs. Fuentelarreina), Pablo Astorga Díaz (Cs. Barrio
Pilar), Begoña Berriatua Ena (Cs. Dr Castroviejo), Ana Isabel
Bezos Varela (Cs. Jose Marva), María José Calatrava Triguero
(Cs. Ciudad Jardín), Carlos Casanova García (Cs. Barrio Pilar),
Angeles Conde Llorente (Cs. Barrio Pilar), Concepción Diaz Laso
(Cs. Fuentelarreina), Emilia Elviro García (Cs. Ciudad Period-
istas), Orlando Enríquez Dueñas (Cs. Fuentelarreina), María Isa-
bel Ferrer Zapata (Cs. El Greco), Froilán Antuña (Cs. Ciudad
Periodistas), Maria Isabel García Lazaro (Cs. Ciudad Periodistas),
Maria Teresa Gómez Rodríguez (Cs. Barrio Pilar), Africa Gómez
Lucena (Cs. La Ventilla), Francisco Herrero Hernández (Cs. La
Ventilla), Rosa Julián Viñals (Cs. DrCastroviejo), Gerardo López
Ruiz Ogarrio (Cs. Barrio Pilar), María Del Carmen Lumbreras
Manzano (Cs. JoseMarva), Sonsoles Paloma Luquero López
(Cs. Ciudad Periodistas), Ana Martinez Cabrera Pelaez (Cs. Barrio
Pilar), Montserrat Nieto Candenas (Cs. La Ventilla), María Ale-
jandra Rabanal Carrera (Cs. Barrio Pilar), Angel Castellanos
Rodríguez (Cs. Ciudad Periodistas), Ana López Castellanos
(Cs. La Ventilla), Milagros Velazquez García (Cs. Barrio Pilar),
and Margarita Ruiz Pacheco (Cs. Dr Castroviejo).
Corresponding Author: Carlos Lahoz, MD, Unidad de Arte-
riosclerosis, Hospital Carlos III, C/ Sinesio Delgado 10, 28029
Madrid, Spain. Tel: þ34 91-4532530; Fax: þ34 91-7336614;
E-mail: clahoz.hcii@salud.madrid.org
Conflict of Interest: The authors report no conflicts of interst.
Funding: This study has been partially financed by an unre-
stricted grant from Novo Nordisk and from Fundación para el
Fomento y Desarrollo de la InvestigaciónClínica (FYDIC).
Lahoz et al
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