Introduction: Evidence is accumulating in favour of a link between erectile dysfunction (ED) and coronary artery disease (CAD). This review attempts to identify which patients, among those with ED and no cardiovascular (CV) disease, should be screened for early, subclinical CAD, which coronary targets should be investigated, and which tests should be used.

Materials and methods: A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1988 to January 2006.

Results: Initial screening of patients with ED may adopt risk assessment office-based approaches to score patients into low, intermediate, or high risk of future cardiovascular events. Attention should be drawn to patients at intermediate risk. Targets for the assessment of subclinical CAD in this subset of patients should include both obstructive (flow-limiting) and nonobstructive (non-flow-limiting) CAD. Some tests address obstructive atherosclerosis by directly assessing coronary flow reserve (i.e., standard exercise stress test, rest/stress myocardial scintigraphy or echocardiography). Other tests are general measures of atherosclerosis burden (not necessarily obstructive) either in the coronary circulation (i.e., coronary calcium score by electron-beam computed tomography), or in extracoronary vessels (i.e., ankle brachial index, carotid intima-media thickness by B-mode ultrasound) as surrogate markers of CAD. Although a systematic use of these measures of nonobstructive atherosclerosis burden has not yet been recommended in the guidelines for coronary risk assessment, their use is progressively being extended from the research area to clinical practice.

Conclusions: ED is definitely a vascular disorder and all men with ED should be considered at risk of CV disease until proven otherwise. Available risk assessment charts should be used to stratify (low, intermediate, and high) the coronary risk score in each patient with ED.