Resuming sexual activity is perfectly safe for most heart patients, according to new guidelines from the American Heart Association (AHA)

-Team@CMHF

• Certain patients, such as those with severe heart disease who have symptoms while at rest, should put off sex until their condition has stabilized.
• But if he can walk briskly or climb two flights of stairs without experiencing chest pain, abnormal heart rhythms, or shortness of breath, he is almost certainly ready to start having sex again, the guidelines say.
• The authors stress, however, that all heart patients should check with their doctor before resuming their sex life.
• The guidelines encourage patients and their partners to discuss any feelings of sex-related anxiety or depression with a health professional.
• Both patients and the patient’s spouse or partner often have anxieties about resuming sexual activity after the patient has been diagnosed with heart disease or has undergone a heart procedure, says Glenn N. Levine, MD, the lead author of the guidelines and a professor of medicine at Baylor College of Medicine, in Houston.
• Sometimes it is actually the partner who is more anxious than the patient.

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• The guidelines, which appear in the journal Circulation and have been endorsed by a host of physicians’ groups, are the first ever from the AHA to focus on heart disease and sex, a subject that gets far too little attention, the authors say.
• Most cardiologists fail to raise the topic with their patients, and they are even less likely to ask about anxiety or depression, Levine says.
• Stephen Kopecky, MD, a cardiologist at the Mayo Clinic, in Rochester, Minnesota, says many patients who have a heart attack or undergo bypass surgery become depressed, which can reduce libido and affect sexual function.
• To make matters worse, he says, avoiding sex can in turn worsen depression.
• That’s why it’s so important for us to talk to patients about this, and tell them this is not the end of their sex life, says Kopecky, who has studied sexual activity in heart patients but did not participate in writing the new guidelines.

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• Heart problems during sex are very rare
• Less than 1% of all heart attacks are triggered by sexual activity, Levine and his coauthors note, and the odds are even lower for people who exercise regularly.
• A sedentary person’s risk of having a heart attack roughly triples during sex, while an active person’s risk rises by just 20%
• But in either case the absolute risk is extremely small, especially since intercourse typically lasts for minutes, rather than hours.
• The chances that a heart-attack survivor will experience another heart attack or die in any given hour is roughly 1 in 100,000, for instance; during sex those odds increase to no more than about 1 in 33,000.
• Still, the guidelines recommend that heart-attack survivors wait at least a week after their attack to resume having sex.
• Patients who have had bypass surgery or other major heart surgery should wait at least six to eight weeks, the authors say, although sex is generally safe several days after minimally invasive surgery to clear blocked blood vessels.

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• The new guidelines address all forms of heart disease, including coronary artery disease, heart failure, heart-rhythm disorders (arrhythmias), and valve problems.
• If a heart patient’s condition is at all uncertain after an initial consultation with a doctor, the guidelines recommend that he or she undergo an exercise stress test, which involves monitoring heart activity and breathing while walking (or running) on a treadmill.
• Even after being cleared for sex, patients may want to take some basic precautions.
• According to the guidelines, doctors should advise their patients to avoid heavy meals and alcohol before sex, use a position that allows for free breathing, and avoid unfamiliar surroundings and partners.
• Most documented cases of sudden death during intercourse involve extramarital sex, the guidelines note.

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• In addition, patients may need to temporarily lower their expectations.
• The achievement of orgasm may require a greater degree of exertion and may not be a realistic initial goal in some patients, Levine and his colleagues write.
• Heart patients’ concerns about intimacy are one of those things that get swept under the rug too often, by not only the caregivers but also the patient and the spouse or the family, Kopecky says and adds that having guidelines like this is very helpful to have it out there and talk about sex and say it is ok to do.

Medscape says

• Patients with stable cardiovascular disease can have sex as long as they can handle other mild or moderate physical activities without symptoms, according to a scientific statement from the American Heart Association.
• Still, it is reasonable for patients diagnosed with cardiovascular disease to receive a comprehensive evaluation from their healthcare provider before resuming sexual activity, the authors stated.
• Patients with unstable disease or severe symptoms should be stabilized before attempting sexual activity, according to the writing group, which was chaired by Glenn Levine, MD, of Baylor College of Medicine in Houston.
• The guidance was endorsed by several other professional societies, including the American College of Cardiology and American Urological Association, and published online in Circulation: Journal of the American Heart Association.
• The authors set out to summarize data on sexual activity and heart disease in order to provide recommendations and foster physician and other healthcare professional communication with patients about sexual activity, the authors wrote.
• In studies conducted primarily among young married men, sexual activity with a person’s usual partner was roughly equal to mild to moderate physical activity, such as climbing two flights of stairs or walking briskly.
• Levine and colleagues noted that that comparison might not apply to older individuals, people who are less physically fit, and patients with cardiovascular disease, who might have to exert themselves more than their healthier counterparts.
• The authors provided several general recommendations for sexual activity among patients with cardiovascular disease
• Women with cardiovascular disease should receive counseling about the safety and advisability of pregnancy and various types of contraception when appropriate.
• It is reasonable for patients with cardiovascular disease to undergo a physical examination and provide a thorough medical history before starting or resuming sexual activity.
• Sexual activity is reasonable for patients with cardiovascular disease who have a low risk of complications following clinical evaluation.
• For those who are not at low risk of cardiovascular complications or who have an unknown cardiovascular risk, exercise stress testing is reasonable to assess exercise capacity and the development of symptoms, ischemia, or arrhythmias.
• Sexual activity is reasonable for patients who can exercise with mild to moderate intensity without angina, excessive dyspnea, ischemic ST-segment changes, cyanosis, hypotension, or arrhythmia.
• Cardiac rehabilitation and regular exercise can be useful to reduce the risk of sexual activity-related cardiovascular complications for patients with cardiovascular disease.
• Patients who develop cardiovascular symptoms while having sex and those with unstable, decompensated, or severe symptomatic cardiovascular disease should not have sex until their condition is stabilized and optimally managed.
• In addition to those general recommendations, the authors provided specific guidance for various conditions and advice for dealing with sexual dysfunction -particularly erectile dysfunction in the setting of cardiovascular disease.
• Although cardiovascular medications are rarely the cause of sexual dysfunction, numerous classes of medications, particularly diuretics and beta-blockers, have been associated with erectile dysfunction.
• The authors recommended that drugs needed for cardiovascular disease not be withheld because of concerns about sexual function.
• Widely available erectile dysfunction drugs — such as the phosphodiesterase-5 (PDE5) inhibitors sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) — are useful for treating that condition in male patients with stable cardiovascular disease, according to the guidelines.
• Safety is unknown, however, in patients with severe aortic stenosis or hypertrophic cardiomyopathy.
• There is also an absolute contraindication to PDE5 inhibitor use in patients receiving nitrate therapy.
• Nitrate therapy should not be administered within 24 hours of the patient using sildenafil or vardenafil, and within 48 hours for tadalafil.
• For postmenopausal women with cardiovascular disease, the authors said that it is reasonable to use local or topical estrogen to treat painful intercourse.
• Levine and colleagues noted the need for further research on sexual activity for specific cardiovascular conditions.
• When possible, pharmacotherapy, device and surgical intervention, registries, and longitudinal studies of patients with cardiovascular disease should specifically include data on sexual activity and function.
• Future studies of interventions to improve sexual activity in the context of cardiovascular disease, including sexual counseling, should address sexual concerns and activity of both men and women, young and old, and both patients and partners.

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