ED Predicts Heart Attacks Better Than Chest Pain: The 2 Tests to Ask For | Dr. Tobias Kohler

Episode Overview

• Host Dr. Gabrielle Lyon (clinician at Strong Medical and author of Forever Strong) interviews Dr. Tobias Köhler (Mayo Clinic urologist, Co-Chair of the Princeton IV Consensus Guidelines on erectile dysfunction and cardiovascular disease, and incoming participant in the Princeton V Guidelines) on how men can shift from reactive to proactive healthcare.
• The conversation frames the penis as a man's most sensitive biomarker—a cardiovascular "check engine light"—explaining how erectile dysfunction (ED), coronary calcium scores, and novel lipid markers like ceramides can predict and prevent fatal cardiac events.
• The episode explores the public health crisis in men's longevity, why men lag 50 years behind women in mortality improvements, and legislative efforts like The State of Men's Health Act to close this gap.
• Dr. Köhler and Dr. Lyon break down the physiology and risks of testosterone replacement therapy versus anabolic steroid abuse, highlighting how supraphysiological dosing triggers fatal cardiac arrhythmias, polypharmacy dangers, and permanently altered hormonal set points.
• The discussion concludes with practical insights into male sexual rehabilitation, covering the mechanics of PDE5 inhibitors, Peyronie's disease, penile implants, and how intense resistance training can build muscle even during complete androgen deprivation for prostate cancer.
• Episode sponsors disclosed by Dr. Lyon include Cozy Earth (promoting the Bubble Cuddle Blanket and Bamboo Sheet Set with promo code DrLyon for up to 20% off), Egglife (egg white wraps and pasta alternatives at egglifefoods.com), and the Ladder App (ladder.fit/DRLYON, with Dr. Lyon disclosing a personal friendship dating back to 2019 with co-founder Lauren Kanski).

Key Concepts

• The Men's Longevity Gap and Healthcare Avoidance: In the United States, the average man lives to age 76 while the average woman dies at age 81 (a 5-year difference), and a 65-year-old man's mortality today is identical to a woman's 50 years ago. Men lead in 9 of the top 10 leading causes of death (including heart disease, cancer, accidental deaths, and kidney disease, with women leading only in Alzheimer's disease), and suicide is 4 times higher in men because they typically choose more aggressive solutions. This gap is compounded by men being 33% less likely to seek healthcare and boys often going 10 to 20 years without seeing a doctor after aging out of pediatrics, unlike girls who transition to OB-GYNs. To address this, The State of Men's Health Act is a bipartisan bill currently on the floor of Congress to establish an Office of Men's Health within the Department of Health and Human Services (HHS), spearheaded by Admiral Brian Christine (the 18th Assistant Secretary for Health at HHS, a urologist). Following the example of the Office of Women's Health—which started 30 years ago and saw female cardiac mortality drop—and countries like Ireland and Brazil that reduced cardiac and cancer deaths via men's health offices, this initiative aims to foster proactive healthcare.
• Erectile Dysfunction as a Cardiovascular Early Warning System: Because normal penile function requires overall health, excellent blood supply, normal nerves, and balanced hormones, it acts as the body's most sensitive biomarker. While the most common symptom before a first heart attack is "nothing" (sudden death without prior chest pain or shortness of breath), the Princeton IV Consensus Guidelines identify ED as the most effective predictor of a future heart attack, especially in younger men. Standard cardiac risk calculators rely heavily on age (where changing age by 5 to 10 years sends calculated risk through the roof), and only 1 calculator currently accounts for ED as a binary risk factor, which increases calculated risk by 10% to 15% on average. When asked if future guidelines might evaluate both hard and soft plaque via CT scan, Dr. Köhler hedges, "I'm not sure," though he notes the Princeton V Guidelines are already in development with preventative cardiologist Dr. Stephen Kopecky to focus more on testosterone, women's health, and evolving data.
• Ceramides and Metabolic Derangement: Ceramides are proteins/lipids specific to different body parts, including the endothelium of the heart, and research from Gerald Shulman's lab shows that diacylglycerol (DAG) and ceramides increase in skeletal muscle to create metabolic derangement. Mayo Clinic developed a ceramide blood test scored from 0 to 12 that predicts the rate of death from a heart attack, and in a "relatively small trial" by Dr. Köhler's group, men with both ED and high ceramide levels had a much higher rate of premature stroke. While Dr. Köhler notes the test is "relatively young in its development" and "some people would say the data is too early" for universal clinical screening, and he is "not certain" or "not sure" if ceramide flux directly or indirectly measures workout efficacy, ceramide levels drop within 1 to 2 weeks of becoming healthier.
• Cholesterol Targets, Statins, and GLP-1s: Although only 24% of the population has an LDL cholesterol level above 130 (according to Dietary Guidelines committee member Tom Brenna), the average LDL of someone having a heart attack is around 106. Citing Dr. Stephen Kopecky, Dr. Köhler notes humans are born with an LDL of 50, which should be the target goal for anyone with a prior cardiac event or visible plaque on a heart CT scan (while those without a cardiac history should aim for an LDL goal of 100). Regarding statins, Dr. Köhler notes that people who take them get less dementia, and states he doesn't "have good evidence to say that statins lower testosterone," adding that if an effect exists, "it's probably a minor one." Looking ahead, Dr. Köhler claims GLP-1 receptor agonists will reduce cardiac risk more than anything else in history. While Dr. Lyon raises concerns about younger populations developing "skinny fat" sarcopenia from GLP-1 use versus treating sarcopenia in a 74-year-old male (where Dr. Köhler hedges that anabolic agents might have utility "in the absence of... people being able to exercise, I guess yes"), Dr. Köhler notes there is "so far no evidence" GLP-1s harm sperm quality and "preliminary evidence" suggests weight loss improves fertility, though "it's relatively early."
• Testosterone Baselines vs. Supraphysiological Dosing: Leaving a hypogonadal man untreated carries a much higher risk of heart attack, all-cause mortality, and cancer than intervening to normalize testosterone. Normal therapeutic testosterone (T) levels are roughly 500 ng/dL, while 1,000 ng/dL is the maximum upper limit of normal ("running a little too hot," where Dr. Köhler hedges he is "kind of" worried but "not certain" of the exact danger). In Dr. Lyon's early clinical career, men starting at 75 milligrams a week would continually increase their dose and feel worse the higher the number got. Men who push supraphysiological levels to 2,000 to 3,000 ng/dL acclimatize to a new set point (expecting energy at 13 out of 10 and erections at 11 out of 10); when they drop back to 500, they feel horrible and often require lifelong androgen replacement at higher-than-average doses. Dr. Köhler doubts heavy abusers ever fully return to baseline, suspecting "some irreversible sequelae," though he caveats, "I can't say with absolute certainty... if somebody is certain, they're usually wrong."
• The Physiology and Myths of Anabolic Steroid Abuse: Young athletes often mistakenly believe steroids will turn a 92 mph fastball into 105 mph, and men seeking an aesthetic look of 12% body fat and a 6-pack often fail to realize that steroids alone without proper diet and training simply make people bulkier and fatter due to ravenous hunger. Up until the early 1980s, medical consensus denied that steroids improved sports performance, until randomized, double-placebo trials gave normal men 400 milligram testosterone injections (targeting average T levels of 2,000) across four groups: weightlifting alone, steroids alone, placebo, and combined weightlifting plus steroids. While the combined group saw exponential bench press and squat gains, natural exercisers gained more strength than sedentary men taking 400 mg of steroids. However, taking 400+ milligrams of testosterone a week makes skeletal muscle growth essentially boundless while tendons and ligaments fail to keep pace, and roughly 50% of heavy users develop deep cystic acne with permanent scars (while women on high-dose T experience irreversible voice changes and permanent clitoromegaly).
• Polypharmacy, Cardiac Remodeling, and Electrical Failure: There are currently only 7 clinical trials looking at men kept consistently at T levels of 2,000 or higher because most high-dose use happens "off the books," meaning doctors "don't have that number" to give users an exact percentage risk of arrhythmia based on blood pressure and duration of use. Extreme bodybuilders rarely use one agent, instead relying on cocktails of 10 to 15 (or 8 to 10) substances, including thyroid agents, aromatase inhibitors, diuretics, and pain medications like Vicodin. Similarly, WrestleMania participants face a cardiac mortality risk roughly 100x higher than the general population, driven by polypharmacy and continuing to eat 3,000 (or as Dr. Lyon suggests, 6,000) calories a day after stopping training, turning muscle into fat. While Dr. Lyon references a potential threshold for endurance running and heart size (mentioning 9 miles a week as a possible limit she has heard, though she notes she doesn't know the exact number), Dr. Köhler explains that steroid abuse causes definitive changes in electrical cardiac signaling. Consequently, most sudden deaths in steroid users are not typical myocardial infarctions from high lipids, but fatal arrhythmias (ventricular fibrillation / V-fib), especially when combined with stimulants like 500 milligrams of caffeine in pre-workout supplements.
• Penile Mechanics, Peyronie's Disease, and Sexual Rehabilitation: The penis is a "use it or lose it" organ that can lose length (half an inch, as Dr. Lyon notes from their prior episode) due to uniform scarring from radiation, diabetes, or lack of use. In contrast, Peyronie's disease is localized scarring causing the penis to bend (most often upward) during erection, triggered by microtraumas during sex when erections are not 10 out of 10 firm, and occurring more frequently in men with Dupuytren's contractures or connective tissue diseases. For ED treatment, PDE5 inhibitors (Cialis, Viagra, Levitra)—with Cialis once called "the weekender" in France for providing weekend-long functional support without causing a 4-hour priapism, and noted by Princeton IV Guidelines as potentially cardioprotective alongside treating erections and nighttime urination, though Dr. Köhler hedges the "jury's still out there"—work in two-thirds (2/3) of men and fail immediately in one-third (1/3) because the tissue is too sick. In the 2/3 who respond, pills last an average of 5 years before disease progression, unless underlying health improves. For aggressive prostate cancer (which causes death in 5 to 10 years if untreated, and where all active treatments like hormone deprivation, radiation, cryoablation, and radical prostatectomy hurt the penis), only 25% to 50% of radical prostatectomy patients recover erections using pills alone. When other methods fail, penile implant surgery requires a 1-month recovery and yields 90% to 95% satisfaction, though it permanently destroys natural tissue so the penis will never work naturally again if removed due to infection.
• Muscle Hypertrophy Without Testosterone: Citing author Michael Easter's "1% Rule" (where everyone knows stairs are healthier than an escalator, yet only 1% take them), Dr. Köhler emphasizes that consistent physical effort trumps hormonal shortcuts. He illustrates this with a clinical case study of a Mayo Clinic physical therapist with a neurological walking disorder who presented in urinary retention with a giant pelvic mass and a PSA in the thousands (where anything above 50 indicates bad prostate cancer). Despite being placed on androgen deprivation therapy that reduced his testosterone to zero, the patient lifted weights daily and returned 2 months later noticeably bigger ("jacked" in his upper body) and hitting personal records (PRs) in the gym.

Quotes

• At 0:01:08 - "The penis is the check engine light, the canary in the coal mine, whatever saying you want to utilize, because in order for it to function on all cylinders, your body has to be willing to give resources there." - Dr. Köhler explaining why erectile function is the most sensitive biomarker of a man's overall vascular, neurological, and hormonal health.
• At 0:02:13 - "If you compare how long men live now at age 65, what their mortality is at age 65, it's identical as to what it was in women 50 years ago. Meaning that essentially, longevity for men is 50 years behind the times." - Dr. Köhler contextualizing the severity of the public health gap in male life expectancy.
• At 0:02:29 - "If you look at the top 10 leading causes of death in the United States, the men are winning in nine of the 10, and the only one that women are winning in is, can you guess?" - Dr. Köhler highlighting male vulnerability to chronic and accidental mortality, which Dr. Lyon correctly identifies as excluding only Alzheimer's disease.
• At 0:08:14 - "I want to turn medicine for men from a reactive event to a proactive event. There's this term agency: you take control for your own action, you are driving your own car, you are your own CEO of your own body." - Dr. Köhler defining the core philosophy needed to overcome men's 33% lower likelihood of seeking medical care.
• At 0:11:13 - "The most effective predictor of having a heart attack that we have is erectile dysfunction, especially in younger men." - Dr. Köhler sharing a foundational conclusion from the Princeton IV Consensus Guidelines.
• At 0:11:50 - "If you're a young man with problems with erections, you should strongly consider getting a coronary calcium score. This is a gated CT scan of your heart which looks at calcium, which again is very, very good at predicting heart attacks down the line." - Dr. Köhler outlining the immediate diagnostic step young men should take when experiencing ED.
• At 0:14:17 - "Essentially, if you can change your ceramide score from 12 to five, your risk of heart attack goes way down." - Dr. Köhler explaining the clinical utility of the Mayo Clinic ceramide blood test and how rapidly it responds to lifestyle interventions.
• At 0:23:43 - "What Dr. Kopecky says is, you know, you're born with an LDL of 50. If you ever have had a cardiac event—so if you see something on a CT scan in the heart that looks like plaque, if you've had a heart attack—your LDL goal should be 50." - Dr. Köhler relaying preventative cardiology targets for patients with established coronary plaque or prior cardiac events.
• At 0:28:01 - "If you have a hypogonadal man and you've got some providers that are very worried about the potential risks of getting the testosterone back into the normal range, well, we know that if we do nothing, the risks of heart attack, all-cause mortality, cancer is a lot higher than when we intervene." - Dr. Köhler clarifying that normalizing clinically low testosterone is cardioprotective compared to leaving hypogonadism untreated.
• At 0:39:41 - "The guys who exercised, but didn't take steroids, had better results than the guys who didn't exercise and were on this crazy dose." - Dr. Köhler summarizing 1980s randomized trials where natural lifters outperformed sedentary men receiving 400 mg testosterone injections.
• At 0:44:56 - "A lot of people that drop dead from steroid abuse, it isn't a typical MI. It can be, because your lipids can be adversely affected and there are case reports of people just dying with crazy high lipids, you know, they use steroids. But most often it has to do with an arrhythmia." - Dr. Köhler explaining how supraphysiological steroid use causes electrical heart remodeling that triggers fatal ventricular fibrillation, especially when mixed with high-dose caffeine.

Takeaways

• Establish a Baseline Testosterone Level at Age 25: Men should get a baseline blood test for testosterone around age 25 when they feel healthy and have normal sexual function, providing an individualized physiological reference point (typically around 500 ng/dL) for later in life.
• Treat Erectile Dysfunction as an Immediate Cardiac Workup Trigger: Do not view ED merely as a quality-of-life issue; if erection problems develop—especially in youth or middle age—request a gated CT scan for a coronary artery calcium (CAC) score and consider a ceramide blood test.
• Use Ceramide Scores to Guide Cardiovascular Triage and Lifestyle Changes: If utilizing the 0-to-12 Mayo Clinic ceramide blood test, treat a score above 6 as a prompt to see a cardiologist for an invasive stress test (and a 12 as requiring immediate cardiology evaluation), while using exercise, diet, and weight loss (such as losing 15 pounds) to drive scores down within 1 to 2 weeks.
• Tailor LDL Cholesterol Targets to Plaque Status: Aim for an LDL cholesterol goal of 100 if you have no cardiac history, but aggressively lower your LDL goal to 50 if you have ever had a heart attack or show visible plaque on a cardiac CT scan.
• Choose Shorter, Proactive Screening Intervals: Adopt Dr. Köhler's personal approach to preventative screening—when given a recommended follow-up range (such as returning in 3 to 7 years after finding 1 polyp during a colonoscopy), choose the earliest end of the window (3 years) to catch pathology early.
• Avoid Partial-Erection Microtraumas and Use Lifestyle to Extend PDE5 Efficacy: Protect against Peyronie's disease by ensuring erections are firm during intercourse to prevent localized microtrauma, and pair PDE5 inhibitors with cardiovascular lifestyle improvements so the medication remains effective beyond the typical 5-year window (or allows you to transition off pills entirely).
• Implement Structured Sexual Rehabilitation After Pelvic Surgery: Following prostate cancer treatment or pelvic surgery, immediately utilize PDE5 inhibitor pills, vacuum erection devices (to stretch tissue and prevent losing half an inch of length), and intracavernosal injections; if function does not return after 1 year, evaluate a penile implant.