Association of Erectile Dysfunction with Incident Atrial Fibrillation: The Multi-Ethnic Study of Atherosclerosis (MESA)

Published:November 15, 2019DOI:



      Erectile dysfunction has been associated with atrial fibrillation in cross-sectional studies, but the association of erectile dysfunction with incident atrial fibrillation is less well established. This study aimed to determine whether erectile dysfunction is independently associated with incident atrial fibrillation after adjusting for conventional risk factors.


      We studied 1760 male participants (mean age 68 ± 9 years) from the Multi-Ethnic Study of Atherosclerosis (MESA), who completed self-reported erectile dysfunction assessment at MESA exam 5 (2010-2012). Cumulative incidence of atrial fibrillation was estimated by Kaplan-Meier analysis. Cox proportional hazards regression was used to calculate the unadjusted and adjusted hazard ratios (HR) using 3 models in which variables were added in a stepwise manner. In model 3, HR was adjusted for age, race and ethnicity, education, smoking status, alcohol use, systolic blood pressure, body mass index, diabetes, anti-hypertensive medication use, lipid-lowering medication use, total cholesterol, and estimated glomerular filtration rate.


      During the median follow-up of 3.8 (interquartile range, 3.5-4.2) years, 94 cases of incident atrial fibrillation were observed. There was a significant difference between males with and without erectile dysfunction for cumulative incident atrial fibrillation rates at 4 years (9.6 vs 2.9%, P < .01). In the fully adjusted model, erectile dysfunction remained associated with incident atrial fibrillation (model 3; HR, 1.66; 95% confidence interval 1.01-2.72, P = .044).


      Among older male participants in this prospective study, we found that self-reported erectile dysfunction was associated with incident atrial fibrillation.


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        • Santhanakrishnan R
        • Wang N
        • Larson MG
        • et al.
        Atrial fibrillation begets heart failure and vice versa: temporal associations and differences in preserved versus reduced ejection fraction.
        Circulation. 2016; 133: 484-492
        • Krishnamoorthy S
        • Lim SH
        • Lip GY
        Assessment of endothelial (dys)function in atrial fibrillation.
        Ann Med. 2009; 41: 576-590
        • Guo Y
        • Lip GY
        • Apostolakis S
        Inflammation in atrial fibrillation.
        J Am Coll Cardiol. 2012; 60: 2263-2270
        • Alonso A
        • Krijthe BP
        • Aspelund T
        • et al.
        Simple risk model predicts incidence of atrial fibrillation in a racially and geographically diverse population: the CHARGE-AF consortium.
        J Am Heart Assoc. 2013; 2e000102
        • Schnabel RB
        • Sullivan LM
        • Levy D
        • et al.
        Development of a risk score for atrial fibrillation (Framingham Heart Study): a community-based cohort study.
        Lancet. 2009; 373: 739-745
        • Feldman HA
        • Goldstein I
        • Hatzichristou DG
        • Krane RJ
        • McKinlay JB
        Impotence and its medical and psychosocial correlates: results of the Massachusetts Male Aging Study.
        J Urol. 1994; 151: 54-61
        • Raheem OA
        • Su JJ
        • Wilson JR
        • Hsieh TC
        The association of erectile dysfunction and cardiovascular disease: a systematic critical review.
        Am J Mens Health. 2017; 11: 552-563
        • Jackson G
        • Boon N
        • Eardley I
        • et al.
        Erectile dysfunction and coronary artery disease prediction: evidence-based guidance and consensus.
        Int J Clin Pract. 2010; 64: 848-857
        • Liu T
        • Meng XY
        • Li T
        • Fu ZL
        • Zhao SG
        • Yao HC
        Atherosclerosis is critical in the pathogenesis of erectile dysfunction.
        Int J Cardiol. 2016; 203: 367-368
        • Vlachopoulos C
        • Aznaouridis K
        • Ioakeimidis N
        • et al.
        Unfavourable endothelial and inflammatory state in erectile dysfunction patients with or without coronary artery disease.
        Eur Heart J. 2006; 27: 2640-2648
        • Yılmaz S
        • Kuyumcu MS
        • Akboga MK
        • et al.
        The relationship between erectile dysfunction and paroxysmal lone atrial fibrillation.
        J Interv Card Electrophysiol. 2016; 46: 245-251
        • Platek AE
        • Hrynkiewicz-Szymanska A
        • Kotkowski M
        • et al.
        Prevalence of erectile dysfunction in atrial fibrillation patients: a cross-sectional, epidemiological study.
        Pacing Clin Electrophysiol. 2016; 39: 28-35
        • Bild DE
        • Bluemke DA
        • Burke GL
        • et al.
        Multi-Ethnic Study of Atherosclerosis: objectives and design.
        Am J Epidemiol. 2002; 156: 871-881
        • Kleinman KP
        • Feldman HA
        • Johannes CB
        • Derby CA
        • McKinlay JB
        A new surrogate variable for erectile dysfunction status in the Massachusetts male aging study.
        J Clin Epidemiol. 2000; 53: 71-78
        • Levey AS
        • Stevens LA
        • Schmid CH
        • et al.
        A new equation to estimate glomerular filtration rate.
        Ann Intern Med. 2009; 150: 604-612
        • Kawut SM
        • Barr RG
        • Lima JA
        • et al.
        Right ventricular structure is associated with the risk of heart failure and cardiovascular death: the Multi-Ethnic Study of Atherosclerosis (MESA)–right ventricle study.
        Circulation. 2012; 126: 1681-1688
        • Chrispin J
        • Jain A
        • Soliman EZ
        • et al.
        Association of electrocardiographic and imaging surrogates of left ventricular hypertrophy with incident atrial fibrillation: MESA (Multi-Ethnic Study of Atherosclerosis).
        J Am Coll Cardiol. 2014; 63: 2007-2013
        • Heckbert SR
        • Wiggins KL
        • Blackshear C
        • et al.
        Pericardial fat volume and incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis and Jackson Heart Study.
        Obesity (Silver Spring). 2017; 25: 1115-1121
        • Beinart R
        • Zhang Y
        • Lima JA
        • et al.
        The QT interval is associated with incident cardiovascular events: the MESA study.
        J Am Coll Cardiol. 2014; 64: 2111-2119
        • O'Neal WT
        • Mazur M
        • Bertoni AG
        • et al.
        Electrocardiographic predictors of heart failure with reduced versus preserved ejection fraction: the multi-ethnic study of atherosclerosis.
        J Am Heart Assoc. 2017; 6
        • Uddin SMI
        • Mirbolouk M
        • Dardari Z
        • et al.
        Erectile dysfunction as an independent predictor of future cardiovascular events.
        Circulation. 2018; 138: 540-542
        • Lin WY
        • Lin CS
        • Lin CL
        • Cheng SM
        • Lin WS
        • Kao CH
        Atrial fibrillation is associated with increased risk of erectile dysfunction: a nationwide population-based cohort study.
        Int J Cardiol. 2015; 190: 106-110
        • Feldman DI
        • Cainzos-Achirica M
        • Billups KL
        • et al.
        Subclinical vascular disease and subsequent erectile dysfunction: the Multiethnic Study of Atherosclerosis (MESA).
        Clin Cardiol. 2016; 39: 291-298
        • Gowani Z
        • Uddin SMI
        • Mirbolouk M
        • et al.
        Vascular erectile dysfunction and subclinical cardiovascular disease.
        Curr Sex Health Rep. 2017; 9: 305-312
        • Tsuneda T
        • Yamashita T
        • Kato T
        • et al.
        Deficiency of testosterone associates with the substrate of atrial fibrillation in the rat model.
        J Cardiovasc Electrophysiol. 2009; 20: 1055-1060
        • Magnani JW
        • Moser CB
        • Murabito JM
        • et al.
        Association of sex hormones, aging, and atrial fibrillation in men: the Framingham Heart Study.
        Circ Arrhythm Electrophysiol. 2014; 7: 307-312
        • Zeller T
        • Schnabel RB
        • Appelbaum S
        • et al.
        Low testosterone levels are predictive for incident atrial fibrillation and ischaemic stroke in men, but protective in women - results from the FINRISK study.
        Eur J Prev Cardiol. 2018; 25: 1133-1139
        • Berger D
        • Folsom AR
        • Schreiner PJ
        • et al.
        Plasma total testosterone and risk of incident atrial fibrillation: the Atherosclerosis Risk in Communities (ARIC) study.
        Maturitas. 2019; 125: 5-10
        • Shiri R
        • Koskimäki J
        • Hakama M
        • et al.
        Prevalence and severity of erectile dysfunction in 50 to 75-year-old Finnish men.
        J Urol. 2003; 170: 2342-2344
        • Selvin E
        • Burnett AL
        • Platz EA
        Prevalence and risk factors for erectile dysfunction in the US.
        Am J Med. 2007; 120: 151-157