Sexual Activity and Ischemic Heart Disease
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- Lange, R.A. & Levine, G.N. Curr Cardiol Rep (2014) 16: 445. doi:10.1007/s11886-013-0445-4
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Human sexuality is an important aspect of health and quality of life. Many patients with ischemic heart disease – and their partners – are concerned that sexual activity could exacerbate their cardiac condition, possibly causing myocardial infarction or cardiac death. Patients with ischemic heart disease who wish to initiate or resume sexual activity should be evaluated with a thorough medical history and physical examination. Sexual activity is reasonable for individuals with no or mild angina and those who can exercise ≥3-5 METS without angina, excessive dyspnea, or ischemic ST segment changes. For the patient who is considered not be at low cardiovascular (CV) risk or in whom the CV risk is unknown, an exercise stress test is reasonable in order to determine his or her exercise capacity and to ascertain if symptoms or ischemia may occur. Regular exercise and cardiac rehabilitation can be effective in reducing the risk of CV complications associated with sexual activity for the patient with ischemic heart disease.
KeywordsSexual activityCoital anginaCoital MIIschemic heart disease
Human sexuality is an important aspect of health and quality of life, even for many older individuals. More than half of people aged 57–85 years and about a third of those aged 75–85 years are sexually active . Physical health is significantly correlated with sexual activity, and sexual activity has been associated with health benefits and longevity [2, 3]. People in very good or excellent health are 1.5 to 1.8 times more likely to report an interest in sex than those in poorer health . At age 55, men in very good or excellent health will on average have 5–7 more years of sexually active life compared to their peers in fair or poor health; for women in good or excellent health the corresponding number is 3–6 more years of sexually active life . In patients with ischemic heart disease, decreased sexual function and activity are common and associated with anxiety and depression [4, 5]. Many patients with ischemic heart disease – and their partners – are concerned that sexual activity could exacerbate their cardiac condition, possibly causing myocardial infarction or cardiac death [6, 7]. Despite these concerns, most patients report that no physician has inquired about potential sexual problems [6, 8]. Health care providers are often uncomfortable addressing these issues because of lack of knowledge about the effects and safety of sexual activity in ischemic heart disease patients. This article presents the information relevant to sexual activity and ischemic heart disease in order to facilitate communication between health care professionals and individuals with coronary artery disease (CAD) regarding sexual activity.
Acute Cardiovascular Effects of Sexual Activity
During sexual activity, systolic arterial pressure usually remains below 170 mmHg in normotensive individuals, and heart rate usually remains below 130 beats/min [9, 17, 18]; however, an occasional subject has an exaggerated hemodynamic response [14, 19]. In a study conducted in patients enrolled in an outpatient cardiac rehabilitation setting , average heart rate monitored during sexual activity was 118 bpm as compared with 113 bpm for daily activities (p = NS); however, in 11 % of these patients with stable CAD, the peak heart rate during intercourse ranged from 150 to 185 bpm, and some individuals experienced an exaggerated blood pressure response (systolic arterial blood pressure >200 mmHg).
These studies conducted in young couples show that sexual intercourse generally involves only moderate physical activity (i.e., 3–4 METS) for a very short duration of time (i.e., several minutes) (Fig. 1). For comparison, the level of activity associated with sexual intercourse (3–4 METS) can be equated to climbing two flights of stairs, walking at 3 mph, bicycling at <10 mph, golfing (pulling the bag cart) and playing horseshoes. Comparing myocardial oxygen demands of sexual intercourse to these modest activities is appealing because it is easily understandable; however, this generalization is unlikely to typify all individuals, especially those who have ischemic heart disease or are not as physically fit [20, 21]. Accordingly, the authors of the Sexual Activity and Cardiovascular Disease AHA Scientific Statement [22••] suggest that sexual activity should be equated to mild-moderate physical activity in the range of 3–5 METS.
Sexual Activity and CV Risk
Sexual Activity and Angina
Almost 10 million individuals in the United States experience angina pectoris . Coital angina that occurs during the minutes or hours following sexual activity (so called, “angina d’amour”) represents less than 5 % of all anginal attacks . The prevalence of coital angina is higher in men than in women, most likely because more middle aged or older men engage in sexual activity than similarly aged women . Coital angina is also more prevalent in inactive individuals with severe CAD who experience ischemic symptoms with minimal or light physical activity; it is uncommon in patients who do not experience angina during moderate or strenuous physical exertion. Since peak systemic arterial pressure and heart rate are higher during maximal exercise testing than during intercourse, virtually all patients with ischemia during intercourse experience ischemic symptoms during exercise stress testing . Accordingly the risk for ischemia is very low during sexual activity if the individual can achieve ≥3-5 METs of energy expenditure without ischemia during exercise testing. In a study of 88 men with known CAD, 50 % of those with ischemia on stress testing experienced ischemia – silent or symptomatic – with sexual activity; of those without exercise-induced ischemia, none had ischemia during intercourse .
Sexual Activity and Myocardial Infarction
Case-crossover studies of the association of sexual activity with myocardial infarction
Despite the fact that sexual activity is associated with an increased risk of CV events, the absolute rate of such events is very low because sexual activity is infrequent and the effects are transient and of short duration, and thus the time during which one is at risk for MI during sexual activity is only a miniscule amount of the total time an individual is at risk for MI. The increased risk for MI associated with one hour of sexual activity weekly is estimated to be 2 to 3 per 10,000 person-years [29•]. It is estimated that a man aged 56–60 years having sex once a week increases his annual risk of MI from 0.464 % to 0.468 % (an annual risk ratio of 1.01) . Muller et al.  report that sexual activity is a lower trigger risk for MI in women than for men.
For the individual who has already experienced an MI, the risk of recurrent MI or death is approximately 10 % annually . In post-MI patients, sexual activity transitorily increases that risk from ten chances in a million per hour to 20 to 30 chances in a million per hour ; engaging in sexual activity once weekly results in an annual risk difference of 0.24 % . In summary, sexual activity is the cause of less than 1 % of all acute MIs .
Sexual Activity and Sudden Death
In an autopsy report of 5559 instances of sudden death in Japan , 34 (0.6 %) were reported to have occurred during sexual intercourse. Two autopsy studies conducted in Germany also reported low rates (0.6 % to 1.7 %) of sudden death linked to sexual activity [32, 33]. Of the individuals who died during intercourse, most (82 % to 93 %) were men and three-fourths (75 %) were having extra-marital sexual activity, most often with a younger companion in an unfamiliar venue and/or after consumption of excessive food or alcohol. The absolute risk increase of sudden death associated with one additional hour of sexual activity weekly is estimated to be less than 1 per 10,000 person-years [29•].
Role of Stress Testing, Cardiac Rehabilitation, and Exercise in Facilitating Sexual Activity
Cardiac rehabilitation that includes exercise training has been shown to (a) decrease peak coital heart rate and (b) increase maximum exercise capacity . In a study of 16 men who underwent a 4 month bicycle exercise training program soon (i.e., 12 to 15 weeks) after their first MI, Holter recordings of heart rate obtained during intercourse before and after completion of the training program demonstrated a 5.5 % average decrease in peak coital heart rate (from 127 beats/min to 120 beats/min) with cardiac rehabilitation. In female patients with unstable angina or non ST-elevation MI, those that completed a cardiac rehabilitation program were 3.77 times more likely to resume sexual activity than those who did not enroll in or complete the program . Regular exercise (i.e., exertion of ≥ 6 METs at least 2 times weekly) appears to reduce the risk of MI triggered by sexual activity [18, 28]. Accordingly, cardiac rehabilitation followed by regular exercise is a reasonable strategy for the individual with stable ischemic heart disease who plans to participate in sexual activity.
CV Medications and Phosphodiesterase-5 (PDE-5) Inhibitors
Beta blockers are considered first-line agents for use in patients with ischemic heart disease . However, use of these agents is often avoided or abandoned because of concerns of sexual dysfunction, particularly in individuals that complain of erectile dysfunction. Importantly, recent studies have not reported a link between beta blocking agents and erectile dysfunction [36, 37•, 38–42]. An analysis of six studies that included almost 15,000 persons found that beta blocker therapy was associated with only a minimal, annual increase in the risk of reported sexual dysfunction (5 per 1000 patients; equivalent to one additional report for every 199 patients treated per year) and in the annual reported rate of impotence (by 3 per 1000 patients) . Several studies have shown that a “nocebo effect” (i.e., the individual’s knowledge that a medication has putatively been linked with erectile dysfunction) is at least as important a contributor to an individual’s erectile dysfunction as any physiological effect of the beta blocker, particularly with contemporary agents [39, 44, 45].
In males with sexual dysfunction due to beta blocker therapy, an appropriate alternative may be nebivolol, which has vasodilating properties (mediated by nitric oxide) and a lower incidence of erectile dysfunction than other beta blocking agents [46, 47] – unless beta blocker therapy is being administered specifically for survival improvement for the individual with ischemic cardiomyopathy or post-MI.
The most recent guidelines regarding sexual activity and CV disease  unequivocally recommend that healthcare providers not withhold CV medications that are known to improve symptoms and/or survival because of concerns that the medications may adversely impact sexual function. If an individual being treated with a CV medication reports sexual dysfunction, it is important to determine if the sexual dysfunction is more likely attributable to underlying cardiac or vascular disease, the nocebo effect, depression, or anxiety.
Fourteen percent of older men report using medication or supplements to improve sexual function , with PDE-5 inhibitors being the most effective and commonly used medications. PDE-5 inhibitors enhance erectile function by preventing cyclic GMP breakdown, which results in increased nitric oxide concentration and vasodilation. Three PDE-5 inhibitors are FDA approved for the treatment of erectile dysfunction in the United States: sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra). Vardenafil and sildenafil are relatively short acting PDE-5 inhibitors, with half-lives of about 4 hours, whereas tadalafil is a long-acting PDE-5 inhibitor with a 17.5 hour half-life. These drugs cause systemic vasodilation with modest reductions in both systolic (≤10 mmHg) and diastolic (≤8 mmHg) systemic arterial pressure [17, 49–51]. Although this is rarely a concern in healthy individuals, in CV patients with low blood pressure or hypotension at baseline, this could be a concern . Vardenafil -- but not tadalafil or sildenafil -- carries a precaution regarding QTc prolongation and should be avoided in individuals with a history of torsade de pointes, congenital QTc prolongation, and those taking drugs that prolong the QT interval (i.e., certain antiarrhythmic agents).
PDE-5 inhibitors are generally safe and effective for treating erectile dysfunction in individuals with stable CAD [49–62, 63•, 64], with no one agent safer or more effective than the other agents. Despite anecdotal case reports that have linked PDE-5 inhibitors to serious cardiac events, large trials and meta-analyses [54, 56, 59, 62] have not associated their use with an increased risk of MI or other serious cardiac events. Subjects administered sildenafil in double-blind, randomized, controlled studies and open-label studies have not experienced an increase in the incidence of MI or death versus placebo or when compared with age-matched expected events [55, 56, 59, 65–67]. Similar results have been reported with tadalafil  and vardenafil . Post-marketing surveys in the United Kingdom  and in the United States (by the FDA)  showed that the MI and mortality rate in men who took sildenafil was similar to that of an age-matched population. Similarly, a post marketing surveillance study of 29,358 German subjects showed no vardenafil-associated CV events [63•]. Post-marketing data regarding CV event rates in men taking tadalafil have yet to be reported.
Nitroglycerin -- both short acting forms (i.e., sublingual or spray) and long acting forms (i.e., isosorbide mononitrate) – is a nitric oxide donor and its ingestion is an absolute contraindication to the use of a PDE-5 inhibitor; this combination may lead to a precipitous decline in systemic arterial pressure . Subjects with myocardial ischemia or infarction should not be administered short or long acting nitrates within 24 hours of vardenafil or sildenafil ingestion  and within 48 hours of tadalafil ingestion . Other than nitrates, all other CV medications can be administered to patients with ischemic heart disease who have taken a PDE-5 inhibitor. For the patient receiving chronic nitrate therapy who wishes to use a PDE-5 inhibitor, the necessity of nitrate therapy -- or consideration of an alternate therapy -- should be evaluated, particularly if the patient has undergone successful coronary revascularization.
Herbal Medications and CV Disease
Many patients take herbal medications that are advertised for the treatment of sexual dysfunction, some of which contain drugs -- such as PDE-5 inhibitors (or substances that are chemically similar) [73, 74], yohimbine , or L-arginine  -- that can interact with CV medications, exhibit sympathomimetic or vasoactive properties, reduce blood pressure, or result in adverse outcomes in CAD patients [49, 71, 75, 77, 78]. The AHA Scientific Statement on Sexual Activity and Cardiovascular Disease [22••] notes that it may be reasonable to caution patients with CV disease regarding the potential for adverse events with the use of herbal medications that are advertised for the treatment of sexual dysfunction.
Specific Ischemic Heart Disease Conditions and Resumption of Sexual Activity
Stable Ischemic Heart Disease
Individuals with mild, stable angina are considered to be at low risk for CV events; conversely those with refractory or unstable angina are considered to be at high risk for such events . For individuals with intermediate symptoms or whose risk is unable to be established during the initial evaluation, exercise stress testing may (a) furnish an assessment of exercise capacity and tolerance; (b) ascertain if ischemic symptoms occur with exertion and, if so, at what level; and (c) assess the severity of exertional ischemia.
Post MI patients who have (a) no ischemic symptoms; or (b) no ischemic electrocardiographic changes with stress testing; or (c) undergone successful and complete coronary revascularization are at low risk for MI with sexual activity. Resumption of sexual activity one week following an uncomplicated MI is reasonable in the patient who has no cardiac symptoms with mild to moderate exertion (e.g., 3–5 METS). This recommendation is based upon the fact that stable post-MI patients safely participate in cardiac rehabilitation as early as 1 week after MI; no studies have directly addressed this issue.
After Percutaneous Coronary Intervention (PCI)
Subjects who undergo PCI and have complete coronary revascularization should be able to resume sexual activity within days of the procedure, provided no femoral vascular access complication has occurred; those with a vascular complication should have an appropriate evaluation before recommencing sexual activity. In patients who have a PCI via radial access, sexual activity can be resumed as early, if not earlier, than when the procedure is performed via the femoral approach. In patients with incomplete coronary revascularization, exercise stress testing can help determine the severity and extent of residual ischemia.
After Coronary Artery Bypass Graft (CABG) Surgery
When CABG is performed via the median sternotomy approach, sternal healing is typically complete within 8 weeks. Since sexual activity may be associated with considerable stress on the chest wall that could compromise sternal wound healing, it should be deferred for 6 to 8 weeks after surgery. Thereafter, sexual activity may be resumed, with studies showing that many patients maintain sexual satisfaction [79, 80]. Minimal access cardiac surgery (i.e., involves a limited or no sternotomy) and robotic-assisted surgery may allow earlier resumption of sexual activity. CABG is usually successful in achieving complete or near complete revascularization. However, when incomplete revascularization or graft failure is suspected, exercise stress testing may be useful in assessing the presence and severity of residual ischemia.
Psychological Issues and Counseling of Sexual Activity and CVD
Decreased sexual function or activity is common in patients with ischemic heart disease [4, 5]. In many patients and their partners, concerns that sexual activity may exacerbate the underlying heart condition or cause death may lead to a decline in sexual activity frequency and satisfaction [4, 81]. Decreased sexual activity after a cardiac event may diminish the patients’ quality of life, adversely affect psychological well-being, strain intimate relationships , and lead to anxiety or depression. Consequently, depression may (a) cause erectile dysfunction in men and (b) decreased libido, dyspareunia and difficulty with arousal and orgasm in women [5, 83, 84]. Accordingly, patients with ischemic heart disease should be screened for the presence of anxiety and/or depression regarding their sexual function [4, 5].
Most heart disease patients (and their partners) believe they are inadequately educated regarding sexual activity by health care providers [85, 86] and desire more information on how to resume their normal sexual activity [86–88]. Although ischemic heart disease patients and their partners consider sexual counseling to be important, it is seldom provided because the provider is uncomfortable discussing sexual issues, lacks adequate knowledge regarding sexual activity and ischemic heart disease, or has limited time [89, 90]. In the rare circumstance when sexual counseling is provided, it is more likely to be offered in written form rather than verbally communicated; information is rarely shared with women patients or partners .
Initiation of a discussion of sexual issues by the health care provider – which can often be facilitated by a questionnaire  - can encourage a frank discussion of sexual concerns the patient and/or partner may harbor. Some general advice that should be shared with the patient includes: (a) being well rested at the time of sexual activity; (b) avoiding unfamiliar venues or partners to minimize stress [92, 93]; (c) avoiding alcohol or heavy meals prior to sexual activity, and (d) finding a position that does not restrict respiration or cause discomfort. In randomized trials conducted in patients with heart disease, sexual counseling reduced fear of sexual activity, improved sexual desire, increased the likelihood of return to normal sexual activity and improved satisfaction with sexual activity [94–98].
Maintaining sexual activity is an important issue for many patients with ischemic heart disease and their partners. Fortunately, most individuals with ischemic heart disease are able to safely engage in sexual activity. Those with good functional capacity and stable symptoms have a low risk of adverse CV events with sexual activity. For the individual with indeterminate or unclear risk, exercise testing can be useful in providing information as to the safety of sexual activity. Individuals with severe or unstable symptoms should first be evaluated, treated and stabilized before participating in sexual activity.
CV medications that are known to improve symptoms and/or survival should not be withheld because of concerns that they may adversely affect sexual function. PDE-5 inhibitors can be safely administered to most patients with stable ischemic heart disease; however, their use is absolutely contraindicated in the patient with recent nitroglycerin use.
Sexual counseling is important to ischemic heart disease patients and their partners; unfortunately, rarely is it provided.
Compliance with Ethics Guidelines
Conflict of Interest
Richard A. Lange and Glenn N. Levine declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.