J Interv Card Electrophysiol DOI 10.1007/s10840-016-0115-8
MULTIMEDIA REPORT
The relationship between erectile dysfunction and paroxysmal lone atrial fibrillation Samet Yılmaz 1 & Mevlüt Serdar Kuyumcu 2 & Mehmet Kadri Akboga 2 & Fatih Sen 2 & Kevser Gülcihan Balcı 2 & Mustafa Mücahit Balcı 2 & Özcan Özeke 2 & Dursun Aras 2 & Sinan Aydoğdu 2
Received: 6 December 2015 / Accepted: 4 February 2016 # Springer Science+Business Media New York 2016
Abstract Purpose Endothelial dysfunction plays a major role in erectile dysfunction (ED). Atrial fibrillation (AF), regardless of subtype, is associated with a prothrombotic state, which is related to endothelial dysfunction. In this study, we aimed to determine whether AF is an independent risk factor for ED. Methods A total of 50 patients diagnosed with paroxysmal lone AF and 80 age-, gender-, and body mass indexmatched controls without AF who admitted to outpatient clinics at a tertiary center were enrolled. Diagnosis of ED was performed by using Sexual Health Inventory for Men (SHIM) questionnaire. Patients with a SHIM score ≤21 were defined as having ED. Results Mean age of patients were 51.8 ± 7.7 and all of the study population were male. Twenty-nine of 50 patients in lone AF group and 25 of 80 patients in control group were diagnosed with ED (58 vs 31.2 %, p = 0.002). Mean SHIM score was significantly lower in lone AF group compared with controls (20.74 ± 2.67 vs 22.39 ± 2.21, p < 0.001). The multivariate stepwise logistic regression analyses showed that lone AF (OR 1.94 (1.44–2.46), p < 0.001), smoking (OR 1.92 (1.35–2.44), p = 0.003), fasting blood glucose (OR 1.51
Electronic supplementary material The online version of this article (doi:10.1007/s10840-016-0115-8) contains supplementary material, which is available to authorized users. * Samet Yılmaz [email protected]
1
Cardiology Clinic, Yozgat State Hospital, Tekke Mah. Camlik Cad, 66200 Yozgat, Turkey
2
Cardiology Clinic, Turkey Yuksek Ihtisas Education and Research Hospital, Ankara 06100, Turkey
(1.10–1.85), p = 0.012), and uric acid levels (OR 1.56 (1.13– 1.92), p = 0.009) were independent predictors of ED. Conclusions Beat-to-beat variation may lead to ED in patients with paroxysmal lone AF and questioning erectile function in patients with lone AF may be recommended. Keywords Paroxysmal atrial fibrillation . Erectile dysfunction . Endothelial dysfunction Atrial fibrillation (AF) is known as the most common arrhythmia in clinical practice and also the most common cause of hospital admissions due to arrhythmia worldwide [1]. The pathophysiology of AF is complex and incompletely understood. In 1997, Minamino et al. first documented the impairment of endothelial function in patients with AF compared with sinus rhythm [2]. Up to date, several studies were performed to find the reasons for this association, and it was reported that beat-to-beat variations in cardiac cycle length, stroke volume, and change in flow velocity produce turbulent shear stress and disruption of endothelial functions in patients with AF [3]. Shear stress in the endothelium may cause alterations in levels of various endothelial-derived substances like nitric oxide (NO), von Willebrand factor (vWF), and selectins that may further result in endothelial dysfunction (ED) [3, 4]. ED is described as the permanent inability to achieve or maintain penile erection for successful sexual intercourse, and it is an important issue that affects the quality of life in men [5]. One of the important mechanisms underlying ED is endothelial dysfunction which causes insufficient relaxation of the vascular smooth muscle of the corpora cavernosa [6]. Inflammatory markers and mediators such as C-reactive protein, intercellular adhesion molecule 1, interleukins, and endothelial/prothrombotic factors (i.e., vWF, tissue plasminogen activator, plasminogen activator inhibitor 1, and
J Interv Card Electrophysiol
fibrinogen) have been shown to be expressed at higher levels in patients with ED similar to patients with AF [7–9]. Endothelial dysfunction and increased inflammation in patients with AF may contribute to development of ED. Based on literature, it seems that there is a possible relationship between AF and ED [10–12]. However, this association has not been studied in the current literature yet. The main hypothesis of this study is that AF is an independent risk factor for development of ED.
1 Methods A total of 50 patients diagnosed with paroxysmal lone AF and 80 age-, gender-, and body mass index (BMI)-matched controls without AF were enrolled for the study. There was not any underlying risk factor for ED for patients in both of the groups and the only identifiable risk factor for ED was solely AF. Rhythm documentation of AF was required for diagnosis of AF. Lone AF was defined as onset of AF in patients 21 were defined as having normal erectile function [15, 16]. Analyses were performed using SPSS 21.0 statistical software (SPSS Inc, Chicago, IL). Continuous data were presented as mean ± standard deviation. To test the distribution pattern, the Kolmogorov–Smirnov test was used. Student’s t test was used to compare groups’ data showing normal distribution. The Mann–Whitney U test was applied to compare the data without a normal distribution. Categorical variables were summarized as percentages and compared with chi-square test. Effects of different variables on ED were calculated in univariate analysis for each. Variables that had unadjusted p value < 0.10 in logistic regression analysis were identified as potential risk markers and included in the full model. We reduced the model using stepwise multivariate logistic regression analyses and eliminated potential risk markers using likelihood ratio tests. A p value < .05 was considered statistically significant, and the confidence interval was 95 %.
2 Results Study population consists of 130 patients, 50 of them have paroxysmal lone AF and 80 of them were age-, gender-, and BMI-matched controls without AF. Mean
J Interv Card Electrophysiol
age of patients were 51.8 ± 7.7 and all of the study population were male. Demographic characteristics and laboratory findings of patients with and without AF are presented in Table 1. Both study groups were similar in regard to age, BMI, sytolic and diastolic blood pressures, and cholesterol levels. However, fasting blood glucose (107.8 ± 18.8 vs 98.2 ± 16.7 mg/dl, p = 0.002) and uric acid levels (6.12 ± 1.14 vs 5.68 ± 1.05 mg/dl, p = 0.001) were significantly higher in lone AF group. Patients in the lone AF group were significantly more smokers than controls (68.0 vs 46.2 %, p = 0.019). Twenty-nine of 50 patients in lone AF group and 25 of 80 patients in control group had a SHIM score of ≤21 which is compatible with ED (58 vs 31.2 %, p = 0.002). Mean SHIM score was significantly lower in lone AF group compared with controls (20.74 ± 2.67 vs 22.39 ± 2.21, p < 0.001) (Fig. 3). The multivariate stepwise logistic regression analyses showed that lone AF (OR 1.94 (1.44–2.46), p < 0.001), smoking (OR 1.92 (1.35–2.44), p = 0.003), fasting blood glucose (OR 1.51 (1.10–1.85), p = 0.012), and uric acid levels (OR 1.56 (1.13–1.92), p = 0.009) were independent predictors of ED (Table 2).
Table 1 Demographic characteristics and laboratory findings of patients with and without atrial fibrillation
3 Discussion In the present study, we showed that prevalence of ED is significantly higher in patients with paroxysmal lone AF compared with apparently healthy individuals. To the best of our knowledge, this is the first study in the literature evaluating association between lone AF and ED. The prevalence of ED in patients with lone AF was 58 % in our study, which is comparable with current literature. It has been shown in various studies that the prevalence of ED is increased in elderly people with or without cardiovascular risk factors [16–18]. Despite the fact that the age of our study population was below 60, age is one of the most important predictor of ED [18]. It has been demonstrated that smoking is associated with increased ED, especially in young males with or without clinical cardiovascular disease [19, 20]. In the study by Feldman et al. [21], it was shown in a population of 513 subjects that the risk of developing moderate or complete ED doubled due to smoking in men aged 40–70 years without hypertension or diabetes mellitus. Similarly, we found that smoking increased the risk of ED about twofold in patients with lone AF.
Lone AF group
Control group
(n = 50)
(n = 80)
Age (years)
52.1 ± 7.2
51.7 ± 7.5
0.625
Smoking, n (%) Body mass index (kg/m2)
34 (68.0)
37 (46.2)
0.019
Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
25.7 ± 4.2 128.2 ± 10.3 83.1 ± 6.2
25.2 ± 4.4 126.8 ± 11.2 82.5 ± 6.6
0.438 0.654 0.538
Ejection fraction (%) Left atrial diameter (mm) Left atrial volume (ml) Fasting blood glucose (mg/dl) Urea (mg/dl) Creatinine (mg/dl) Uric acid (mg/dl) Total cholesterol (mg/dl) LDL cholesterol (mg/dl) HDL cholesterol (mg/dl) Triglycerides (mg/dl) Hemoglobin (g/dl) Platelet count (×109/l) White blood cell count (×109/l)
61.5 ± 7.2 44.1 ± 9.2 67.5 ± 21.5 107.8 ± 18.8 28.2 ± 13.5 0.9 ± 0.2 6.12 ± 1.14 176.8 ± 39.2 119.4 ± 31.2 37.4 ± 8.2 165.5 ± 72.2 13.2 ± 1.70 249 ± 83 9.2 ± 3.24
62.2 ± 6.6 36.5 ± 8.2 49.5 ± 18.7 98.2 ± 16.7 27.7 ± 14.1 0.9 ± 0.1 5.68 ± 1.05 172.5 ± 38.9 117.1 ± 30.6 36.8 ± 7.9 162.2 ± 68.9 13.6 ± 1.96 256 ± 72 8.9 ± 2.75
0.439 0.003
MULTIMEDIA REPORT
The relationship between erectile dysfunction and paroxysmal lone atrial fibrillation Samet Yılmaz 1 & Mevlüt Serdar Kuyumcu 2 & Mehmet Kadri Akboga 2 & Fatih Sen 2 & Kevser Gülcihan Balcı 2 & Mustafa Mücahit Balcı 2 & Özcan Özeke 2 & Dursun Aras 2 & Sinan Aydoğdu 2
Received: 6 December 2015 / Accepted: 4 February 2016 # Springer Science+Business Media New York 2016
Abstract Purpose Endothelial dysfunction plays a major role in erectile dysfunction (ED). Atrial fibrillation (AF), regardless of subtype, is associated with a prothrombotic state, which is related to endothelial dysfunction. In this study, we aimed to determine whether AF is an independent risk factor for ED. Methods A total of 50 patients diagnosed with paroxysmal lone AF and 80 age-, gender-, and body mass indexmatched controls without AF who admitted to outpatient clinics at a tertiary center were enrolled. Diagnosis of ED was performed by using Sexual Health Inventory for Men (SHIM) questionnaire. Patients with a SHIM score ≤21 were defined as having ED. Results Mean age of patients were 51.8 ± 7.7 and all of the study population were male. Twenty-nine of 50 patients in lone AF group and 25 of 80 patients in control group were diagnosed with ED (58 vs 31.2 %, p = 0.002). Mean SHIM score was significantly lower in lone AF group compared with controls (20.74 ± 2.67 vs 22.39 ± 2.21, p < 0.001). The multivariate stepwise logistic regression analyses showed that lone AF (OR 1.94 (1.44–2.46), p < 0.001), smoking (OR 1.92 (1.35–2.44), p = 0.003), fasting blood glucose (OR 1.51
Electronic supplementary material The online version of this article (doi:10.1007/s10840-016-0115-8) contains supplementary material, which is available to authorized users. * Samet Yılmaz [email protected]
1
Cardiology Clinic, Yozgat State Hospital, Tekke Mah. Camlik Cad, 66200 Yozgat, Turkey
2
Cardiology Clinic, Turkey Yuksek Ihtisas Education and Research Hospital, Ankara 06100, Turkey
(1.10–1.85), p = 0.012), and uric acid levels (OR 1.56 (1.13– 1.92), p = 0.009) were independent predictors of ED. Conclusions Beat-to-beat variation may lead to ED in patients with paroxysmal lone AF and questioning erectile function in patients with lone AF may be recommended. Keywords Paroxysmal atrial fibrillation . Erectile dysfunction . Endothelial dysfunction Atrial fibrillation (AF) is known as the most common arrhythmia in clinical practice and also the most common cause of hospital admissions due to arrhythmia worldwide [1]. The pathophysiology of AF is complex and incompletely understood. In 1997, Minamino et al. first documented the impairment of endothelial function in patients with AF compared with sinus rhythm [2]. Up to date, several studies were performed to find the reasons for this association, and it was reported that beat-to-beat variations in cardiac cycle length, stroke volume, and change in flow velocity produce turbulent shear stress and disruption of endothelial functions in patients with AF [3]. Shear stress in the endothelium may cause alterations in levels of various endothelial-derived substances like nitric oxide (NO), von Willebrand factor (vWF), and selectins that may further result in endothelial dysfunction (ED) [3, 4]. ED is described as the permanent inability to achieve or maintain penile erection for successful sexual intercourse, and it is an important issue that affects the quality of life in men [5]. One of the important mechanisms underlying ED is endothelial dysfunction which causes insufficient relaxation of the vascular smooth muscle of the corpora cavernosa [6]. Inflammatory markers and mediators such as C-reactive protein, intercellular adhesion molecule 1, interleukins, and endothelial/prothrombotic factors (i.e., vWF, tissue plasminogen activator, plasminogen activator inhibitor 1, and
J Interv Card Electrophysiol
fibrinogen) have been shown to be expressed at higher levels in patients with ED similar to patients with AF [7–9]. Endothelial dysfunction and increased inflammation in patients with AF may contribute to development of ED. Based on literature, it seems that there is a possible relationship between AF and ED [10–12]. However, this association has not been studied in the current literature yet. The main hypothesis of this study is that AF is an independent risk factor for development of ED.
1 Methods A total of 50 patients diagnosed with paroxysmal lone AF and 80 age-, gender-, and body mass index (BMI)-matched controls without AF were enrolled for the study. There was not any underlying risk factor for ED for patients in both of the groups and the only identifiable risk factor for ED was solely AF. Rhythm documentation of AF was required for diagnosis of AF. Lone AF was defined as onset of AF in patients 21 were defined as having normal erectile function [15, 16]. Analyses were performed using SPSS 21.0 statistical software (SPSS Inc, Chicago, IL). Continuous data were presented as mean ± standard deviation. To test the distribution pattern, the Kolmogorov–Smirnov test was used. Student’s t test was used to compare groups’ data showing normal distribution. The Mann–Whitney U test was applied to compare the data without a normal distribution. Categorical variables were summarized as percentages and compared with chi-square test. Effects of different variables on ED were calculated in univariate analysis for each. Variables that had unadjusted p value < 0.10 in logistic regression analysis were identified as potential risk markers and included in the full model. We reduced the model using stepwise multivariate logistic regression analyses and eliminated potential risk markers using likelihood ratio tests. A p value < .05 was considered statistically significant, and the confidence interval was 95 %.
2 Results Study population consists of 130 patients, 50 of them have paroxysmal lone AF and 80 of them were age-, gender-, and BMI-matched controls without AF. Mean
J Interv Card Electrophysiol
age of patients were 51.8 ± 7.7 and all of the study population were male. Demographic characteristics and laboratory findings of patients with and without AF are presented in Table 1. Both study groups were similar in regard to age, BMI, sytolic and diastolic blood pressures, and cholesterol levels. However, fasting blood glucose (107.8 ± 18.8 vs 98.2 ± 16.7 mg/dl, p = 0.002) and uric acid levels (6.12 ± 1.14 vs 5.68 ± 1.05 mg/dl, p = 0.001) were significantly higher in lone AF group. Patients in the lone AF group were significantly more smokers than controls (68.0 vs 46.2 %, p = 0.019). Twenty-nine of 50 patients in lone AF group and 25 of 80 patients in control group had a SHIM score of ≤21 which is compatible with ED (58 vs 31.2 %, p = 0.002). Mean SHIM score was significantly lower in lone AF group compared with controls (20.74 ± 2.67 vs 22.39 ± 2.21, p < 0.001) (Fig. 3). The multivariate stepwise logistic regression analyses showed that lone AF (OR 1.94 (1.44–2.46), p < 0.001), smoking (OR 1.92 (1.35–2.44), p = 0.003), fasting blood glucose (OR 1.51 (1.10–1.85), p = 0.012), and uric acid levels (OR 1.56 (1.13–1.92), p = 0.009) were independent predictors of ED (Table 2).
Table 1 Demographic characteristics and laboratory findings of patients with and without atrial fibrillation
3 Discussion In the present study, we showed that prevalence of ED is significantly higher in patients with paroxysmal lone AF compared with apparently healthy individuals. To the best of our knowledge, this is the first study in the literature evaluating association between lone AF and ED. The prevalence of ED in patients with lone AF was 58 % in our study, which is comparable with current literature. It has been shown in various studies that the prevalence of ED is increased in elderly people with or without cardiovascular risk factors [16–18]. Despite the fact that the age of our study population was below 60, age is one of the most important predictor of ED [18]. It has been demonstrated that smoking is associated with increased ED, especially in young males with or without clinical cardiovascular disease [19, 20]. In the study by Feldman et al. [21], it was shown in a population of 513 subjects that the risk of developing moderate or complete ED doubled due to smoking in men aged 40–70 years without hypertension or diabetes mellitus. Similarly, we found that smoking increased the risk of ED about twofold in patients with lone AF.
Lone AF group
Control group
(n = 50)
(n = 80)
Age (years)
52.1 ± 7.2
51.7 ± 7.5
0.625
Smoking, n (%) Body mass index (kg/m2)
34 (68.0)
37 (46.2)
0.019
Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg)
25.7 ± 4.2 128.2 ± 10.3 83.1 ± 6.2
25.2 ± 4.4 126.8 ± 11.2 82.5 ± 6.6
0.438 0.654 0.538
Ejection fraction (%) Left atrial diameter (mm) Left atrial volume (ml) Fasting blood glucose (mg/dl) Urea (mg/dl) Creatinine (mg/dl) Uric acid (mg/dl) Total cholesterol (mg/dl) LDL cholesterol (mg/dl) HDL cholesterol (mg/dl) Triglycerides (mg/dl) Hemoglobin (g/dl) Platelet count (×109/l) White blood cell count (×109/l)
61.5 ± 7.2 44.1 ± 9.2 67.5 ± 21.5 107.8 ± 18.8 28.2 ± 13.5 0.9 ± 0.2 6.12 ± 1.14 176.8 ± 39.2 119.4 ± 31.2 37.4 ± 8.2 165.5 ± 72.2 13.2 ± 1.70 249 ± 83 9.2 ± 3.24
62.2 ± 6.6 36.5 ± 8.2 49.5 ± 18.7 98.2 ± 16.7 27.7 ± 14.1 0.9 ± 0.1 5.68 ± 1.05 172.5 ± 38.9 117.1 ± 30.6 36.8 ± 7.9 162.2 ± 68.9 13.6 ± 1.96 256 ± 72 8.9 ± 2.75
0.439 0.003
