June 26, 2025
The 2023 Princeton IV (P4) consensus guidelines bring a game-changing message to clinicians: Erectile dysfunction (ED) is not just a quality-of-life issue but also a red flag for cardiovascular disease (CVD). This multidisciplinary expert panel urges healthcare professionals to view ED as a risk-enhancing marker for silent coronary artery disease (CAD), especially in younger men who appear otherwise healthy. The consensus guidelines were published in a 2024 issue of The Journal of Sexual Medicine.
The first author in a Mayo Clinic Proceedings 2024 article, Tobias S. Kohler, M.D., M.P.H., a urologist at Mayo Clinic in Rochester, Minnesota, has been at the forefront of men's health for over two decades. Dr. Kohler is the current president of the Sexual Medicine Society of North America, and his leadership in the field makes this an especially relevant opportunity for regional health professionals. Dr. Kohler says, "We have one of the nation's top experts guiding care for ED and cardiovascular risk — right here in Rochester."
Why ED deserves serious attention
ED often occurs 2 to 5 years before men experience heart attacks. Because the penile arteries are only 1 to 2 mm wide, they're among the first vessels to show signs of atherosclerosis. In many cases, ED is the earliest — and only — visible symptom of cardiovascular disease.
The P4 panel recommendations confirm that ED is a strong, independent predictor of cardiac events, even when traditional risk factors such as cholesterol, diabetes and blood pressure are controlled for. In short, ED is the body's "check engine light" for heart disease.
New guidelines: Reassess risk with better tools
Dr. Kohler and the P4 team advocate using coronary artery calcium (CAC) scoring in patients with ED and borderline (5% to 7.5%) or intermediate (7.5% to 20%) 10-year atherosclerotic CVD risk. This quick, noninvasive CT scan is one of the most sensitive and specific ways to detect subclinical CAD, especially in patients ages 40 to 60, whose risk is often underestimated.
Finding a high CAC score (above 100) can lead to early intervention: statins, aspirin, lifestyle counseling and, in some cases, cardiology referral. This single test can turn a routine men's health visit into a lifesaving diagnosis.
Is sex safe in patients with cardiac conditions?
Yes, for most. If men can walk a mile or climb two flights of stairs without symptoms, sexual activity is safe. For men with recent myocardial infarction, heart failure or unstable angina, stress testing or cardiology clearance is advised before initiating ED therapy.
Dr. Kohler and colleagues provide clear, pragmatic tools for stratifying risk and guiding ED management in men with known or suspected heart disease.
PDE5 inhibitors: Safe and possibly cardioprotective
Phosphodiesterase-5 (PDE5) inhibitors — such as sildenafil and tadalafil — remain first line therapy for ED. The P4 recommendations, however, suggest that these medications may offer more than symptom relief. Multiple large studies show that men taking PDE5 inhibitors have lower rates of heart attack, heart failure and death.
In a study of over 70,000 men, PDE5 inhibitor use was associated with:
- A 25% reduction in all-cause mortality.
- A 39% reduction in cardiovascular death.
- A 17% lower rate of heart failure.
- A 15% lower rate of revascularization.
Though these findings are observational, the potential for PDE5 inhibitors to play a role in cardiovascular disease prevention is gaining momentum, and Dr. Kohler is helping lead that conversation nationally.
Lifestyle changes equal better erections and better hearts
Lifestyle changes such as weight loss, exercise and smoking cessation significantly improve ED and lower cardiac risk. In one randomized trial, structured diet and exercise led to ED resolution in a third of participants. Dr. Kohler emphasizes that the same choices that help the penis help the heart.
Crucially, ED can be a powerful motivator. Men are often more receptive to diet and exercise recommendations when improved sexual function is the goal. Framing lifestyle changes in this way boosts engagement and adherence.
One simple question can save a life
Dr. Kohler encourages all healthcare professionals, especially primary healthcare professionals, to ask: "Are you having any trouble with erections?"
This simple question opens the door to uncovering subclinical heart disease, managing mental health and promoting wellness. Many men won't mention ED unless asked, and physicians often overlook the opportunity. Yet the implications for long-term health are profound.
When to refer
Patients who don't respond to PDE5 inhibitors — or who have complicated cardiovascular profiles — may benefit from specialty referral. Mayo Clinic offers comprehensive management options, including:
- Intracavernosal injections.
- Penile implant surgery.
- Stress testing and CAC scoring.
- Multidisciplinary sexual health and cardiology care.
As a nationally recognized expert, Dr. Kohler provides evidence-based, compassionate care that integrates urology, cardiology and men's health at a single center.
Conclusion
ED is more than a sexual issue — it's a cardiovascular warning sign. The Princeton IV consensus recommendations, with Dr. Kohler as first author, empowers clinicians to use ED as a gateway to detect and prevent heart disease. Dr. Kohler says that by asking the right questions and knowing when to refer, physicians can not only improve quality of life but also save lives.
For more information
Kloner RA, Burnett AL, Miner M, et al. Princeton IV consensus guidelines: PDE5 inhibitors and cardiac health. The Journal of Sexual Medicine. 2024;21(2):90.
Kohler TS, Kloner RA, Rosen RC, et al. The Princeton IV consensus recommendations for the management of erectile dysfunction and cardiovascular disease. Mayo Clinic Proceedings. 2024;99(9):1500.
Refer a patient to Mayo Clinic.