International Journal of Cardiology 197 (2015) 166
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor Association of atrial fibrillation and erectile dysfunction: Reply
To the Editor: We thank Dr Aksu et al. for their interests regarding our report of the association between atrial fibrillation (AF) and erectile dysfunction (ED) [1]. Dr Aksu and his colleague raised two concerns regarding the risk of ED in patients with AF [2]. First, they questioned if the increased ED risk in patients with AF is confounded by the underlying comorbidities, such as coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), diabetes mellitus, and previous stroke. Indeed, similar to our findings, patients with AF are associated with more comorbidities than those without AF [3–5]. In the present study, we did our best to minimize the bias with taking these comorbidities into cox regression analysis model [1]. The presence of AF, diabetes mellitus, and hyperlipidemia did predict the risk of ED, however, others comorbidities, such CAD, COPD, CKD, hypertension, and previous stroke could not reach the statistic significances. After adjusting for the covariates of AF, diabetes mellitus and hyperlipidemia, both of AF and hyperlipidemia associated with the increased risk of ED independently [1]. These results clearly pointed out the association between AF and ED is not simply due to the underlying comorbidities of AF. Second, they questioned the insufficient drugs information in our study population, which might be another confounder in evaluation the risk of ED [6,7]. It is difficult to obtain the information of all potential drugs from the National Health Insurance Research Database and we acknowledge this in our study limitation. However, the information regarding the use of beta-blockers and spironolactone, two common drugs used in the study population, has been provided. Their effects on ED risk have been evaluated and fully addressed in the present article. In summary, we admit that the evidence derived from a retrospective cohort study is generally lower methodological quality than that from the prospectively randomized trial because a retrospective cohort study is subject to have many biases due to lack of the necessary adjustments or possibly unmeasured or unknown confounding factors. However, based on the previous basic data indicating the shared pathophysiology linking AF and ED, such as systemic inflammation, oxidative stress and endothelial dysfunction [8,9], our study provides the first clinical evidence suggesting the association between AF and ED. Future prospective randomized studies are necessary to clarify the effects of AF on ED. Conflict of interest All authors report no conflicts of interest.
http://dx.doi.org/10.1016/j.ijcard.2015.06.088 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
References [1] W.Y. Lin, C.S. Lin, C.L. Lin, S.M. Cheng, W.S. Lin, C.H. Kao, Atrial fibrillation is associated with increased risk of erectile dysfunction: a nationwide population-based cohort study, Int. J. Cardiol. 190 (2015) 106–110. [2] K. Kalkan, U. Aksu, Association of atrial fibrillation and erectile dysfunction, Int. J. Cardiol. 195 (2015) 76. [3] A.K. Kakkar, I. Mueller, J.P. Bassand, D.A. Fitzmaurice, S.Z. Goldhaber, S. Goto, et al., International longitudinal registry of patients with atrial fibrillation at risk of stroke: Global Anticoagulant Registry in the FIELD (GARFIELD), Am. Heart J. 163 (2012) 13–19. [4] A.S. Go, E.M. Hylek, K.A. Phillips, Y. Chang, L.E. Henault, J.V. Selby, et al., Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study, JAMA 285 (2001) 2370–2375. [5] J.Y. Le Heuzey, G. Breithardt, J. Camm, H. Crijns, P. Dorian, P.R. Kowey, et al., The RecordAF study: design, baseline data, and profile of patients according to chosen treatment strategy for atrial fibrillation, Am. J. Cardiol. 105 (2010) 687–693. [6] E. Selvin, A.L. Burnett, E.A. Platz, Prevalence and risk factors for erectile dysfunction in the US, Am. J. Med. 120 (2007) 151–157. [7] F. Fusco, M. Franco, N. Longo, A. Palmieri, V. Mirone, The impact of non-urologic drugs on sexual function in men, Arch. Ital. Urol. Androl. 86 (2014) 50–55. [8] T.T. Issac, H. Dokainish, N.M. Lakkis, Role of inflammation in initiation and perpetuation of atrial fibrillation: a systematic review of the published data, J. Am. Coll. Cardiol. 50 (2007) 2021–2028. [9] M. Guazzi, R. Arena, Endothelial dysfunction and pathophysiological correlates in atrial fibrillation, Heart 95 (2009) 102–106.
Wen-Yu Lin Chin-Sheng Lin Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Cheng-Li Lin Management Office for Health Data, China Medical University, Taichung, Taiwan College of Medicine, China Medical University, Taichung, Taiwan Chia-Hung Kao College of Medicine, China Medical University, Taichung, Taiwan Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan Corresponding author at: Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, No. 2, Yuh-Der Road, Taichung 404, Taiwan. E-mail address: [email protected]. 6 June 2015
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor Association of atrial fibrillation and erectile dysfunction: Reply
To the Editor: We thank Dr Aksu et al. for their interests regarding our report of the association between atrial fibrillation (AF) and erectile dysfunction (ED) [1]. Dr Aksu and his colleague raised two concerns regarding the risk of ED in patients with AF [2]. First, they questioned if the increased ED risk in patients with AF is confounded by the underlying comorbidities, such as coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), diabetes mellitus, and previous stroke. Indeed, similar to our findings, patients with AF are associated with more comorbidities than those without AF [3–5]. In the present study, we did our best to minimize the bias with taking these comorbidities into cox regression analysis model [1]. The presence of AF, diabetes mellitus, and hyperlipidemia did predict the risk of ED, however, others comorbidities, such CAD, COPD, CKD, hypertension, and previous stroke could not reach the statistic significances. After adjusting for the covariates of AF, diabetes mellitus and hyperlipidemia, both of AF and hyperlipidemia associated with the increased risk of ED independently [1]. These results clearly pointed out the association between AF and ED is not simply due to the underlying comorbidities of AF. Second, they questioned the insufficient drugs information in our study population, which might be another confounder in evaluation the risk of ED [6,7]. It is difficult to obtain the information of all potential drugs from the National Health Insurance Research Database and we acknowledge this in our study limitation. However, the information regarding the use of beta-blockers and spironolactone, two common drugs used in the study population, has been provided. Their effects on ED risk have been evaluated and fully addressed in the present article. In summary, we admit that the evidence derived from a retrospective cohort study is generally lower methodological quality than that from the prospectively randomized trial because a retrospective cohort study is subject to have many biases due to lack of the necessary adjustments or possibly unmeasured or unknown confounding factors. However, based on the previous basic data indicating the shared pathophysiology linking AF and ED, such as systemic inflammation, oxidative stress and endothelial dysfunction [8,9], our study provides the first clinical evidence suggesting the association between AF and ED. Future prospective randomized studies are necessary to clarify the effects of AF on ED. Conflict of interest All authors report no conflicts of interest.
http://dx.doi.org/10.1016/j.ijcard.2015.06.088 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
References [1] W.Y. Lin, C.S. Lin, C.L. Lin, S.M. Cheng, W.S. Lin, C.H. Kao, Atrial fibrillation is associated with increased risk of erectile dysfunction: a nationwide population-based cohort study, Int. J. Cardiol. 190 (2015) 106–110. [2] K. Kalkan, U. Aksu, Association of atrial fibrillation and erectile dysfunction, Int. J. Cardiol. 195 (2015) 76. [3] A.K. Kakkar, I. Mueller, J.P. Bassand, D.A. Fitzmaurice, S.Z. Goldhaber, S. Goto, et al., International longitudinal registry of patients with atrial fibrillation at risk of stroke: Global Anticoagulant Registry in the FIELD (GARFIELD), Am. Heart J. 163 (2012) 13–19. [4] A.S. Go, E.M. Hylek, K.A. Phillips, Y. Chang, L.E. Henault, J.V. Selby, et al., Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study, JAMA 285 (2001) 2370–2375. [5] J.Y. Le Heuzey, G. Breithardt, J. Camm, H. Crijns, P. Dorian, P.R. Kowey, et al., The RecordAF study: design, baseline data, and profile of patients according to chosen treatment strategy for atrial fibrillation, Am. J. Cardiol. 105 (2010) 687–693. [6] E. Selvin, A.L. Burnett, E.A. Platz, Prevalence and risk factors for erectile dysfunction in the US, Am. J. Med. 120 (2007) 151–157. [7] F. Fusco, M. Franco, N. Longo, A. Palmieri, V. Mirone, The impact of non-urologic drugs on sexual function in men, Arch. Ital. Urol. Androl. 86 (2014) 50–55. [8] T.T. Issac, H. Dokainish, N.M. Lakkis, Role of inflammation in initiation and perpetuation of atrial fibrillation: a systematic review of the published data, J. Am. Coll. Cardiol. 50 (2007) 2021–2028. [9] M. Guazzi, R. Arena, Endothelial dysfunction and pathophysiological correlates in atrial fibrillation, Heart 95 (2009) 102–106.
Wen-Yu Lin Chin-Sheng Lin Division of Cardiology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan Cheng-Li Lin Management Office for Health Data, China Medical University, Taichung, Taiwan College of Medicine, China Medical University, Taichung, Taiwan Chia-Hung Kao College of Medicine, China Medical University, Taichung, Taiwan Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan Corresponding author at: Graduate Institute of Clinical Medical Science and School of Medicine, College of Medicine, China Medical University, No. 2, Yuh-Der Road, Taichung 404, Taiwan. E-mail address: [email protected]. 6 June 2015
