International Journal of Impotence Research (2008) 20, 507–511 & 2008 Nature Publishing Group All rights reserved 0955-9930/08 $30.00 www.nature.com/ijir
ORIGINAL ARTICLE
The prevalence of erectile dysfunction in heart failure patients by race and ethnicity K Hebert1, B Lopez1, J Castellanos2, A Palacio3,4, L Tamariz3,4 and LM Arcement5 1
Division of Cardiology, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA; Division of Internal Medicine, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA; 3 Humana Health Services Research Center, Department of Medicine, University of Miami, Miami, FL, USA; 4Veterans Affairs Medical Center, Department of Medicine, Miami, FL, USA and 5Leonard J Chabert Medical Center, Department of Medicine, Houma, LA, USA 2
Erectile dysfunction (ED) is a common problem in male patients with heart failure (HF). However, no study was found that estimates the prevalence of ED by US ethnic groups with HF. We conducted an observational, cross-sectional study of patients enrolled in a HF disease management program in two sites Louisiana (N ¼ 329; 178 white, 99 black) and Florida (N ¼ 52; Hispanic). All male patients with an ejection fraction p40% were included. The Sexual Health Inventory for Men was used to estimate the prevalence of ED. Overall prevalence of ED was 89% and ED severity did not vary by race/ethnic group. Race/ethnic group differences were found for age, New York Heart Association functional classification, and blood pressure. Hispanic patients had the lowest unadjusted and adjusted prevalence rate of ED (81, 85%) compared to Black (90, 95%) and White (91, 92%) patients. There is a high prevalence of ED in Hispanic, Black and White ethnic groups with HF. International Journal of Impotence Research (2008) 20, 507–511; doi:10.1038/ijir.2008.35; published online 14 August 2008 Keywords: heart failure; erectile dysfunction; Hispanic Americans; African Americans
Introduction Erectile dysfunction (ED) is defined as the consistent inability to attain or maintain a penile erection of sufficient quality to permit satisfactory sexual intercourse.1 The prevalence rate of ED in the general population has been shown to vary across countries and race/ethnicity2,3 and increase with age.4,5 In the Men’s Attitudes to Life Events and Sexuality study, which included men from eight countries (United States, United Kingdom, Germany, France, Italy, Spain, Mexico and Brazil) aged 20–75 years ED prevalence ranged from 22% in the United States to 10% in Spain.2 However, in another population study in Brazil, Italy, Japan and Malaysia the age-adjusted prevalence of ED was 34% in Japan, 22% in Malaysia, 17% in Italy and
Correspondence: Dr B Lopez, Division of Cardiology, Department of Medicine, Miller School of Medicine, University of Miami, Jackson Memorial Hospital North Wing 210, 1611 NW 12th Avenue, Miami, FL 33136, USA. E-mail:
[email protected] Received 16 May 2008; revised 26 June 2008; accepted 11 July 2008; published online 14 August 2008
15% in Brazil.6 Regarding race/ethnic differences in the United States, results have been inconsistent. Results from a recent survey among male patients aged 40 or older reported that the prevalence of ED was 21.9% in white, 24.4% in Black and 19.9% in the Hispanic population.5 In contrast, results from the National Health and Nutrition Examination Survey of men aged 20 years old and above indicated Hispanic ethnicity was associated with elevated risk for ED compared with black and white men.3 In addition to age, which has been found to be the strongest predictor of ED in the general population, several other factors such as heart disease have also been found to be associated with ED.4–6 Not surprisingly, the prevalence of ED is higher in patients with heart disease and has been found to range between 42 and 75%.7–10 When ED is examined in patients with heart failure (HF) the prevalence grows to 84%.11 The alarming high prevalence of ED among HF patients coupled with the increasing rates of congestive HF in industrialized nations suggests that ED is an important medical concern in patients with congestive HF. Although reports on the prevalence of ED in HF patients have begun to appear in the literature, little is known regarding the prevalence of ED in
Erectile dysfunction by race/ethnic group K Hebert et al 508
congestive HF patients from ethnic minority populations. Given that the prevalence of ED has been previously found to vary across countries and race/ethnicity in the general population, it is likely that the prevalence of ED in HF patients will vary across different ethnic minority populations. Given the paucity of research regarding the prevalence of ED in HF patients across race and ethnicity, the aim of this study was to determine the prevalence of ED in HF patients by race/ethnic group. Specifically, we compare the prevalence of ED in White, Black and Hispanic patients with HF enrolled in disease management programs.
Materials and methods Study population We conducted an observational prospective crosssectional study that included 329 patients from two sites (Louisiana and Florida). At the Louisiana site (N ¼ 277), all indigent white (N ¼ 178) and black (N ¼ 99) male patients enrolled into a HF disease management program at Leonard J Chabert Medical Center (LJCMC) in Houma, Louisiana and completed the Sexual Health Inventory for Men (SHIM) questionnaire. The LJCMC in Houma, Louisiana, is a safetynet rural hospital providing care primarily to uninsured and underinsured patients with a severely depressed socioeconomic background. Patient population served at this hospital is largely indigent; more than 55% of total encounters involve patients who are below 200% of the federal poverty level and/or are uninsured. In 2006, 7.9% of claims were from Medicare, 21.6% of claims were from Medicaid and 50.5% of claims were from uncompensated care.12 Study recruitment took place from August 1999 to December 2007. Patient consent was obtained to enroll into a prospective electronic data registry and the Ochsner Medical Review Board approved this study. At the Florida site (N ¼ 52), we included all Hispanic male patients enrolled in the Heart Failure Clinic at Jackson Memorial Hospital, from October 2007 to March 2008, with an ejection fraction p40% and a completed SHIM. Informed consent was obtained to enroll into a prospective electronic data registry. Patient population served at this hospital is largely indigent; 56% of Hispanic men in this study were classified as indigent and did not have any type of insurance, 9% had Medicare, 17% had Medicaid and 18% had private insurance. The patient population is also largely comprised of immigrants with 98% born outside the United States. General demographic features of study population were obtained such as age, comorbidities (for example, hypertension, diabetes, ischemia), New York Heart Association (NYHA) class and medications. The protocol was approved by the institutional review board of the Miller School of Medicine University of Miami. International Journal of Impotence Research
Erectile dysfunction All the participants were administrated SHIM to measure the ED at the baseline of the study. A Spanish version of the questionnaire and a Spanishspeaking health care worker were available to avoid any language barrier in the assessment. SHIM consists of five questions designed to cover the major constituents of ED. Respondents are asked about their experience related to ED during the past 6 months. Responses are recorded on a five-point Likert scale ranging from Rarely (1) to Almost Always (5). The instrument has satisfactory reliability and validity and has been used extensively in population-based studies.13,14 A score of 21 or lower on the SHIM scale has been used to identify ED. On the basis of SHIM the patients were categorized in (1) no ED, (2) mild ED, (3) moderate ED and (4) severe ED.
NYHA class New York Heart Association functional classification was recorded for all patients. The NYHA classification has been widely used as a simple summary measure of a clinician’s assessment of a patient’s functional limitation due to congestive HF over the past three decades.15,16 This relatively simple tool of classification of functional status has been shown to correlate with symptom burden, signs of congestion, quality of life, exercise capacity and prognosis.17–19
Statistical analyses All analyses were conducted using SPSS 15. Ethnic/race differences in prevalence rates were analyzed using Crosstabs. For categorical variables, the w2-statistic was used to evaluate group differences. For continuous variables, analysis of variance was used to evaluate group differences. A P-value less than 0.05 was considered statistically significant. Logistic regression was used to adjust prevalence rates for group differences.
Results Sample demographic and clinical characteristics are presented on Table 1. The rate of angiotensinconverting enzyme/angiotensin receptor blocker (ACE/ARB) and b-blockers was high, 96 and 98%, respectively. The prevalence rates by race/ethnic group are presented in Table 2. Although, white patients had the highest prevalence of (91%) compared to Black (90%) and Hispanic (81%) patients, this difference was only significant between white and Hispanic patients. No significant difference was found in severity of ED among the three ethnic groups.
Erectile dysfunction by race/ethnic group K Hebert et al Table 1 Characteristics of study participants Characteristic N Age (year) M, s.d.
No ED 329 56.12 (11.80)
Race/ethnicity, n (%) White Black Hispanic
178 (54) 99 (30) 52 (16)
Drug therapy b-Blocker, n (%) ACE inhibitor/ARB, n (%) Spironolactone, n (%)
322 (98) 317 (96) 39 (12)
Medical history NYHA, n (%) I II III IV ICM, n (%) DCM, n (%) Systolic BP, mm Hg, M, (s.d.) Diastolic BP, mm Hg, M, (s.d.) HDL, mg/100 ml, M, (s.d.) LDL, mg/100 ml, M, (s.d.) Ejection fraction, M, (s.d.) QRS duration (ms), M, (s.d.) Atrial fibrillation, n (%) Glomerular filtration rate (ml/min/1.73 m2), M, (s.d.)
509
Table 2 Prevalence of ED by race/ethnic subgroups
78 124 97 23 129 193 129.59 76.60 42.45 107.76 26.40 114.20 51 75.38
(24) (39) (30) (7) (39) (59) (24.44) (15.54) (18.99) (77.17) (8.45) (28.36) (16) (27.84)
Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; DCM, dilated cardiomyopathy; HDL, high-density lipoprotein; ICM, ischemic cardiomyopathy; LDL, low-density lipoprotein; NYHA, New York Heart Association.
Demographic and clinical characteristics by ethnicity are presented in Table 3. Hispanic patients were more likely to fall into an NYHA class I or II than Black and White patients (P ¼ 0.039). Black patients were significantly younger than white and Hispanic patients (Po0.001). White patients had significantly lower systolic and diastolic blood pressure than black and Hispanic patients (Po0.001). No significant group differences were found for rates of diabetes, body mass index (BMI) value, use of b-blocker, ACE inhibitor or spironolactone medications, and high-density lipoprotein (HDL) and low-density lipoprotein (LDL) levels. Logistic regression was used to adjust prevalence rates for group differences in age, NYHA class and blood pressure. The age, NYHA class and blood pressure adjusted prevalence rates for White, Black and Hispanic patients were 92, 95, and 85%, respectively.
Discussion This study examined the prevalence of ED across three race/ethnic groups of patients with HF. In line
White, n (%) Black, n (%) Hispanic, n (%) Total, n (%)
16 10 10 36
Any ED
Mild ED
Moderate ED
(9)a 162 (91)a 29 (16) (10) 89 (90) 18 (18) (19)a 42 (81)a 8 (15) (11) 293 (89) 55 (17)
51 39 15 105
(29) (39) (29) (32)
Severe ED 82 32 19 133
(46) (32) (37) (40)
Abbreviation: ED, erectile dysfunction. a Po0.05.
with past research,11 we found that the overall prevalence of ED was 89% in this sample. Unadjusted and adjusted prevalence rates indicated that black and white patients had a similar rate of ED in this study and Hispanic patients had the lowest prevalence of ED. This finding is consistent with some general population studies.5 For example, Hispanic population in the MARSH study, which evaluated the prevalence of ED in male patients older than 40 years old, had the lowest ED prevalence compared with other ethnic groups.5 To our knowledge this is the only study that examined race/ethnic differences in the prevalence of ED in HF patients and as such provides preliminary evidence that ED may vary by race/ethnicity in HF patients. Our finding that ED may vary by race/ethnicity in HF patients is expected given that racial/ethnic disparities in access to care continue to persist in the United States.20–23 Regarding cardiac care, Black populations have received the greatest focus whereas Hispanic populations have received little attention.21 Recent reports suggest that in addition to decreased access to care, patients from race/ ethnic minority groups do not receive the same quality of care24 and do not have access to quality providers compared to white patients.25–27 These health disparities in access to care among Black and Hispanic patients have been frequently attributed to differences in socioeconomic status (SES) and more recently neighborhood composition.28 In comparison to patients of low SES, patients of high SES have at their disposal a wide range of resources, including money, knowledge, prestige, power and social connections that they can use to their own health advantage.29 In addition to SES, several aspect of race/ethnic differences in access to care may be associated with race/ethnic differences in the prevalence of ED including lack of insurance coverage,22,28 lack of knowledge concerning available resources,30 language differences28,31 and cultural factors influencing patient–physician communication.11,32 For example, a recent study reported that Mexican-American males had feelings of embarrassment with their primary care physicians and expected that the International Journal of Impotence Research
Erectile dysfunction by race/ethnic group K Hebert et al 510
Table 3 Demographic and clinical characteristics by ethnicity Characteristic N Age (year) M, s.d. Drug therapy b-Blocker, n (%) ACE inhibitor/ARB, n (%) Spironolactone, n (%) Medical history NYHA, n (%)* I II III IV Systolic BP, mm Hg, M, (s.d.) Diastolic BP, mm Hg, M, (s.d.) HDL, mg/100 ml, M, (s.d.) LDL, mg/100 ml, M, (s.d.) BMI, M, (s.d.) Waist circumference, M, (s.d.) Diabetes mellitus, n (%)
White
Black
Hispanic
P-value
178 57.92 (12.24)a
99 52.42 (10.40)a,b
52 57.17 (11.33)b
0.001
173 (97.2) 172 (96.6) 19 (10.7)
99 (100.0) 97 (98.0) 10 (10.1)
50 (96.2) 48 (94.1) 10 (19.2)
0.193 0.461 0.198 0.039
47 63 50 14 124.88 71.81 41.55 111.82 31.13 41.99 77
(27.0) (36.2) (28.7) (8.0) (22.31)a,b (14.06)a,b (12.39) (97.78) (7.02) (5.93) (43.3)
24 33 37 4 136.29 82.70 45.12 106.90 31.24 41.75 38
(24.5) (33.7) (37.8) (4.1) (25.43)a (15.52)a (14.11) (33.31) (7.61) (7.10) (38.4)
7 28 10 5 133.11 81.48 39.89 90.52 32.18 41.10 22
(14.0) (56.0) (20.0) (10.0) (26.40)b (15.12)b (42.27) (30.27) (13.90) (7.37) (43.1)
0.000 0.000 0.230 0.310 0.757 0.743 0.716
Abbreviations: ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BMI, body mass index; BP, blood pressure; HDL, high-density lipoprotein; LDL, low-density lipoprotein; NYHA, New York Heart Association. a,b Values sharing superscripts within the same row are significantly different at Po0.05. *For NYHA Hispanic patients were significantly different from black patients (P-value ¼ 0.012) and marginally different from white patients (P-value ¼ 0.051).
physician ask first about erectile problems.32 Indeed, another study reported that Black and White patients with cardiovascular disease reported ED, whereas only 50% of Hispanic patients reported ED.11 Racial/ethnic differences in endothelial dysfunction33–35 may also be in part responsible for race/ ethnic differences in the prevalence of ED. Research in this area suggests that ED may be caused by endothelial dysfunction.36,37 Endothelial dysfunction is commonly defined as an altered endothelial response that diminishes nitric oxide bioavailability, impairing vasodilatation.36 Conditions that negatively affect endothelial function such as hypertension,38 dyslipidemia,39 diabetes,40 metabolic syndrome,41 central obesity42 have been found to be associated with cardiovascular disease and vary by race and ethnicity. For instance among patients with diabetes, ED prevalence increases with diabetes duration, poor glycemic control, presence of microvascular complications, diuretic treatment and cardiovascular disease.43 In our study, we did not find group differences on rates of diabetes, BMI value, use of b-blocker, ACE inhibitor or spironolactone medications, and HDL and LDL levels. Group differences were found for age, NYHA class and mean blood pressure, which fell within the prehypertensive category for White, Black and Hispanic populations.44 These differences may have influenced with race/ethnic differences in the prevalence of ED found. International Journal of Impotence Research
Limitations Race/ethnic subpopulations were drawn from different geographical areas (Hispanic subpopulation from Miami and White and Black subpopulations from Louisiana), which may have influenced results. However, the majority of patients from both sites were of low SES. This was because patients for this study were drawn from two safety-net hospitals that traditionally have provided services to patients from low socioeconomic backgrounds and indigent patients. Conclusions There is a high prevalence of ED in Hispanic, Black and White ethnic groups with HF. Health care providers should screen all their HF patients for ED given the newer oral medication available for treatment.
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