Giving sexual advice to cardiac patients is an important aspect of their overall management, no matter the cardiovascular disease (CVD) condition [1]. Sexual health is an integral component of human (male and female) well being. The World Health Organisation made it clear that all individuals have a fundamental right to sexual health, including “freedom from…factors inhibiting sexual response and impairing sexual relations…[and] organic disorders, disease and deficiencies that interfere with reproductive function” [2]. In 1978 I concluded “It should be routine policy to advise patients and their spouses (update this to partners) on sexual activity, whether they have had an infarction or are regularly attending with angina pectoris. Most patients with ischaemic heart disease can enjoy normal sexual relations without risk” [3]. Unfortunately 35 years later, though sexual counselling of patients with CVD and their partners is recognised to be an important part of recovery, advice is still not routinely provided [1–4]. The bold paper in this issue from the Netherlands depressingly confirms we have hardly moved on [5]. Of 980 members of the Netherlands Society of Cardiology mailed 53.9 % responded—were the rest too embarrassed to answer?—and only 16 % said they discussed sexual function routinely with 2 % referring for specialised advice.

54 % hid behind “lack of initiative of the patient” and 43 % could not make time, whilst 35 % admitted to a lack of training. The importance of initiating the enquiry has been emphasised repeatedly in several key-note publications with sample questions provided [6, 7]. Lack of time is simply a pathetic excuse whilst lack of training or understanding is recognising an honest need for further education which should be made available [8, 9]. Indeed, most studies of CVD patients and their partners suggest health care professionals provide inadequate advice about sexual activity and wish more information was provided—in other words the health care professional needs to ask pro-actively [10, 11]. Studies have clearly shown that sexual counselling improves knowledge about CVD and sex, helps relieve anxiety, increases confidence and alleviates the fear of sexual activity [12].

The cardiovascular responses to sexual activity including intercourse is similar to mild to moderate non-sexual effort—walking 1 mile (1.6 km) in 20 min on the flat or briskly climbing two flights of stairs in 10 s [13]. In longstanding (not casual) relationships the heart rate and blood pressure response is similar to that experienced during other aspects of normal daily life. Coital death is rare (±1 % of sudden deaths) and occurs usually as a result of casual sex with an age mismatch, following too much to eat and drink [14].

The need for cardiologists to be actively involved in providing sexual advice is increasing as the link between erectile dysfunction (ED) and CVD has identified endothelial dysfunction as the common denominator, with ED predicting cardiovascular events and mortality in asymptomatic men and also frequently being a problem after a CV event [6, 12]. It is also becoming a problematic area in grown up congenital heart disease [15].

There is no doubt that sexual activity is a concern for patients with CVD and their partners (it may be one person’s problem but it is a couple’s concern) and some cardiologists looking after them [8]. Because counselling is such an important component of treatment, cardiologists need to understand the physiological aspects of sex, the risks involved, and the therapy available. The Dutch have done us a service—advice is not given routinely (an unmet need) and established algorithms are not being followed with the result that needless anxiety, depression and frustration is not addressed. I agree entirely that a physician’s feelings and attitudes should never get in the way of patient care, however discussing sex is not everyone’s “cup of tea” so a programme needs to be established whereby advice is readily available (a designated colleague, routinely as part of a rehabilitation programme).

In 35 years the world has changed dramatically, yet advice on sex by cardiologists has stood still. It is belatedly time to realise sex and the heart is within the cardiologist’s remit—let’s put some fun back into our patients’ lives (it is safe to do so for the majority) by educating and advising individuals and couples.

Let Step One be “Ask the Question”.