ED and Heart Health: Why Erectile Dysfunction Can Be an Early Warning

Erections depend on healthy blood vessels. That is why erectile dysfunction can show up before other signs of heart disease.

An erection is a blood-flow event. Arteries in the penis have to widen and fill, and they are small, so problems with blood vessels can show up there earlier than in the larger arteries of the heart. That is the reasoning behind a finding that has held up in research for two decades: erectile dysfunction can be an early warning sign of cardiovascular disease.

What the research found

One of the clearest studies followed men 55 and older who were in the placebo group of a large prostate cancer prevention trial. Over several years, men who developed ED had a higher rate of later heart attacks, strokes and other cardiovascular events than men who did not, even after accounting for age, blood pressure, cholesterol, diabetes and smoking.² The authors described the size of the association as comparable to smoking or a family history of heart attack, and concluded that ED should prompt investigation of cardiovascular risk factors.²

Shared risk factors

The conditions that damage blood vessels are the same ones linked to ED: high blood pressure, diabetes, high cholesterol, smoking and obesity.¹ That overlap is why a doctor evaluating ED will ask about all of them.

What this means for treatment

The American Urological Association's guideline calls for a medical history and evaluation as part of ED care.⁴ For a man with ED, that has two practical consequences:

• It can catch something important. A blood pressure reading or a blood sugar test prompted by ED can lead to earlier treatment of a heart risk.
• It decides what is safe. Men who take nitrates for chest pain cannot take any PDE5 inhibitor, and men taking alpha-blockers need caution.³

What does ED health say about your overall health?

ED is often treated as a heart-health signal because the penile arteries are small and fail early. A pooled analysis of 14 follow-up studies (92,757 men, average follow-up 6.1 years) found men with ED had a higher risk than men without it of total cardiovascular events (relative risk 1.44), heart attack (1.62), stroke and other cerebrovascular events (1.39) and death from any cause (1.25). The link to cardiovascular death alone was weaker and not statistically significant (1.19).⁵ The risk was higher in younger men and in men at intermediate cardiovascular risk, and higher when ED was measured with a questionnaire than with a single question.⁵ These are associations from cohort studies, not proof that ED causes heart disease. For men in their 40s and 50s, they are one reason to read our guide to erectile dysfunction in young men as more than a bedroom question.

Can men with heart disease take ED medication?

Often yes, but only after a clinician has checked that the heart can handle sexual activity. The Princeton III consensus panel recommended using exercise ability and stress testing to confirm that each man's cardiovascular health matches the physical demands of sex before prescribing ED treatment.⁶ Two points are firm on the drug labels. Nitrates in any form rule out sildenafil, and the Cialis label says tadalafil is not recommended for men who had a heart attack in the last 90 days, have unstable angina or angina during sex, have had heart failure of NYHA class 2 or greater in the last 6 months, have uncontrolled arrhythmia, low blood pressure (below 90/50 mm Hg) or uncontrolled high blood pressure, or have had a stroke in the last 6 months. Those groups were not included in its trials.³⁷

The label rules are about safety today, not about long-term harm from the drugs. A 2024 meta-analysis of 16 cohort studies (1,257,759 people, 10.5% treated with a PDE5 inhibitor) linked PDE5 inhibitor use to fewer major cardiovascular events (relative risk 0.78) and lower all-cause mortality (0.70), but observational data like these cannot show the drugs caused the benefit, and the authors call for randomized trials.⁸ Our guides to ED and blood pressure medicines and ED medication interactions cover the drug combinations in more detail.

What should a man with ED and heart disease ask his doctor?

• Is my heart stable enough for sex? Stable means no recent heart attack, unstable angina or uncontrolled blood pressure or rhythm problems.⁷⁶
• Do any of my medicines contain a nitrate? That includes nitroglycerin and isosorbide products.³⁷
• Do I take an alpha-blocker or several blood pressure medicines? The combination can lower blood pressure further.³
• Should my cardiovascular risk be checked now? ED can be the first sign of a problem that has no other symptoms.²⁶

Lifestyle helps both

Because the risk factors overlap, the same changes help both. In a randomized trial of obese men with ED, weight loss and more exercise improved erectile function scores over two years.⁹

Where treatment fits

Once a clinician has reviewed your health, there are several treatment options, from PDE5 inhibitor tablets to devices, injections and implants.^4,1 Whatever the treatment, the evaluation comes first.

Questions readers ask

Can erectile dysfunction be a sign of heart disease?

It can. ED and heart disease share risk factors, and a large study found men who developed ED had a higher rate of later cardiovascular events.

Should I see a doctor about ED even if I feel healthy?

Yes. A medical evaluation is part of ED care and can identify blood pressure, cholesterol or blood sugar problems early.

Can I take ED medication if I have heart disease?

It depends on your condition and medications. Anyone taking nitrates must not take a PDE5 inhibitor. A clinician needs to review your history.

Is ED an early sign of heart disease at a young age?

It can be. In a pooled analysis of 14 studies, the link between ED and later cardiovascular events was stronger in younger men than in older men, which is one reason a medical check-up is worth having.

Is it safe to take Viagra or Cialis with heart disease?

Often yes once a clinician confirms the heart is stable, but never with nitrates. The Cialis label says it is not recommended soon after a heart attack or stroke, or with unstable angina, uncontrolled blood pressure or certain heart failure.

Further reading

Part of our guide: ED and Your Health: The Heart, Blood Pressure, Diabetes and Age

• What Causes Erectile Dysfunction in Young Men?
• Is ED Related to Diabetes? What the Research Shows
• ED and Blood Pressure Meds: Which Ones, If Any, Affect Erections?
• Sildenafil Headache: How Common Is It?