It is not uncommon to find risk factors unknown by the patient such as diabetes, dyslipidemia, or hypertension. In 1999, a panel of experts elaborated the guidelines for cardiovascular evaluation in patients with ED, then revised and published them for the second Princeton consensus.

These guidelines recommend an evaluation for ED patients, and establish three levels of cardiovascular risk:

• Low-risk category: Asymptomatic; <3 risk factors for coronary artery disease ([CAD] excluding gender); uncomplicated past myocardial infarction (MI); left ventricular dysfunction (LVD)/ congestive heart failure (CHF) (New York Heart Association [NYHA] class I); mild, stable angina (evaluated and/or being treated); post-successful coronary revascularization; controlled hypertension; mild valvular disease.
• Intermediate-risk category: >3 risk factors for CAD (excluding gender); recent MI (>2, <6 weeks); moderate, stable angina; LVD/CHF (NYHA class II); non-cardiac sequelae of atherosclerotic disease (e.g., stroke, peripheral vascular disease).
• High-risk category: High-risk arrhythmias; unstable or refractory angina; recent MI (<2 weeks); LVD/CHF (NYHA class III/IV); uncontrolled hypertension; moderate-to-severe valvular disease; hypertrophic obstructive, and other cardiomyopathies.

Additionally, each level has corresponding management recommendations:

• Low-risk category: Primary care management, consider all first-line therapies, reassess at regular intervals (6–12 months).
• Intermediate-risk category: Specialized CV testing (e.g., exercise treadmill test [ETT], Echo), restratification into high risk or low risk based on the results of CV assessment.
• High-risk category: Priority referral for specialized CV management, treatment for sexual dysfunction to be deferred until cardiac condition stabilized and dependent on specialist recommendations.