Erectile dysfunction (ED) is related to cardiovascular risk factors by an impairment of endothelial function. Therefore, symptoms of ED are probably to precede cardiovascular disease and events. Moreover, endothelial dysfunction is common in patients with decreased left ventricular ejection fraction (LVEF). Hence, left ventricular dysfunction probably results in a decreased erectile function. A total of 192 cardiovascular high-risk patients from the EROSS Programme (Evaluation of Role of Sexual Dysfunction in the Saarland Programme) were evaluated regarding onset and severity of ED using the IIEF-5 questionnaire. LVEF was measured with magnetic resonance imaging, angiographically or echocardiographically. Prevalence of ED was 80.6%. Patients with moderate or severe impairment of ejection fraction had a significant increase of ED (p = 0.001). Multivariate analysis identified LV dysfunction as an independent risk factor for ED independent of heart failure symptoms (p = 0.001). Moreover, symptoms of ED appeared 3.04 +/- 7.2 years prior to the cardiovascular event (p = 0.005). LVEF is an independent risk factor for the development or increase of ED in cardiovascular high-risk patients, probably caused by an impairment of endothelial function. Hence, ED is suggested to be an early symptom of generalised cardiovascular disease and events. Thus, cardiovascular evaluation is recommended in patients with ED providing the opportunity of optimised preventional treatment.