Sexual Activity and the Cardiac Patient
Coronary heart disease is the major cause of morbidity and mortality in the elderly population in the United States, affecting both men and women. Advances in cardiac therapies have enabled cardiac patients to remain both physically and sexually active even into their eighties and nineties. However, both patients and physicians are reluctant to discuss sexual issues. A significant number of patients will have sexual dysfunction following a diagnosis of cardiovascular disease. It is therefore imperative that physicians initiate discussions regarding sexual activity and potential risks to the patient such as myocardial infarction, sudden death, and arrhythmia. Risk stratification based on objective criteria and in particular cases, functional testing, may be useful in counseling patients regarding individual risk. Newly available pharmacologic therapies such as sildenafil may be useful, but must be used with caution in patients with known cardiovascular disease.
It has been estimated that in the next decade the number of adults, particularly aged adults, will outnumber children and younger individuals. Cardiovascular disease manifests as a function of increasing age. Advances in health care and therapies are allowing individuals to remain active into their eighties and nineties, and this includes sexual activity. However, sexual problems are common in a large portion of the cardiac patient population. It is therefore important for the clinician to know how to counsel patients who may be at increased risk for cardiac events regarding the relative risks of sexual activity, and to be knowledgeable about the effects of new pharmacologic therapies. It is imperative that clinicians provide explicit advice about sexual activity, particularly to patients with known cardiac disease. Patients are often reluctant to address this issue (as are some physicians). Reassurance based on risk assessment, and in some cases functional testing, may allow patients to continue normal sexual activity after cardiac diagnoses.
Sexual activity may be to some degree equated to other physical exertion, e.g., walking, lifting, light housework. Additional hemodynamic changes may be related to psychological factors such as apprehension, fear, or sexual activity with an unfamiliar partner. In general, for most individuals, it appears that sexual activity is similar to mild to moderate intensity exercise; this is true for individuals with or without coronary disease. Heart rates rarely exceed 130 beats/min and systolic blood pressures are generally less than 170 mm Hg. However, there is some individual variation, based on age and general physical conditioning, with some patients attaining heart rates up to 180 beats/min with orgasm (healthy young volunteers without known heart disease). It has also been documented that in patients with known coronary artery disease, sexual activity may provoke increased arrythmia.
In comparing sexual activity with other forms of activity, the most commonly used clinical measure is the MET, or metabolic equivalent of energy expenditure. For comparison, walking at 2 mph on level ground would equate to 2 METs; walking at 3 mph, 3 METs. Sexual activity preorgasm averages 2-3 METs; sexual activity during orgasm 3-4 METs. Compared to higher-intensity physical exertion, such as cycling at 10 mph (6-7 METs) or walking to stage 4 of a Bruce protocol on the treadmill (13 METs), this exertion is relatively modest.
There appear to be differences in energy expenditure during different types of sexual activity: self-stimulation, partner stimulation, and coitus with man on top and coitus with woman on top. Again, significant variability exists, but on average, in healthy young volunteers, peak heart rate was greater for man on top coitus than with woman on top (heart rate 127±23 vs. 110±24). In metabolic expenditure, this would translate to 2.0-5.4 METs for man on top coitus vs. 2.5-3.0 METs for woman on top coitus. This is compared to peak heart rates of 102±14 for noncoital activity.
Following a cardiac diagnosis (angina, myocardial infarction (MI), congestive heart failure (CHF), significant arrhythmia) or cardiac procedure such as coronary artery bypass, coronary interventional procedure, automatic implantable cardioverter/defibrillator (AICD) placement or cardiac transplant, it has been estimated that approximately 25% of patients return to the previous level of sexual function, 25% do not resume any sexual activity, and 50% return to sexual activity at a reduced level. This varies depending on cardiac condition, with more bypass patients returning to their previous level of function than those post-MI or with angina. Immediately following percutaneous transluminal coronary angioplasty, there appeared to be a less negative impact on sexual function than with bypass surgery; however, at 15 months there was no significant difference. With other cardiac procedures, i.e., cardiac transplantation, pacemaker placement, or AICD implantation, approximately 50% of patients reported no change in sexual activity, with about a 30% improvement in the transplant population, a 41% worsening in reported sexual functioning in the AICD population, and a very modest improvement, approximately 8%, in the pacemaker group.
The reasons generally stated are fear of death, fear of repeated event (i.e., MI, arrhythmia, or cardiac decompensation), fear on the part of a spouse of inducing an event, etc.
It should be emphasized that coital death is a rare event, with only 0.6% of sudden death cases attributable to sexual intercourse. In evaluating risk of MI associated with intercourse, it has been estimated that fewer than 1% of MIs occur during sexual activity. Although sexual activity can trigger MI, the relative risk is low with a slight increase in risk within 2 hours of sexual activity. However, even in high-risk individuals with previous MI the annual risk is 1.10% vs. 1.0% in the population at large. This risk appears to apply equally to men and women.
Patients can therefore be risk stratified and counseled about safely returning to or continuing sexual activity. Those considered low risk would be asymptomatic patients with fewer than three risk factors for coronary artery disease, stable angina, recent uncomplicated MI, mild valvular heart disease, mild CHF, controlled hypertension, or post successful revascularization. These patients can generally be managed medically and followed at regular intervals.
Intermediate risk patients would include those with more than three risk factors for coronary artery disease, recent MI, moderate CHF (New York Heart Association class II), peripheral vascular disease, etc. These patients may benefit from functional testing, i.e., exercise treadmill tests (ETT), echocardiography, or nuclear imaging studies with restratification based on results of testing. ETT can assist in gauging cardiac risk of sexual activity, both for induction of ischemia or arrhythmia. In general, if a patient can achieve 5 METs on ETT without demonstrable ischemia or significant arrhythmia, they are generally not at high risk to resume normal sexual activities. Similarly, if echocardiography does not yield evidence of more than moderate left ventricular dysfunction, resumption of sexual activity is probably safe.
High-risk patients would be those with unstable angina, poorly controlled hypertension, severe CHF (New York Heart Association class III/IV), MI within 2 weeks, significant arrhythmias, severe cardiomyopathies, and moderate to severe valvular disease. These patients should be referred for cardiovascular evaluation and stabilization prior to recommending resumption of sexual activity.
Many factors can interfere with return to sexual activity following cardiac events (fear of death, performance anxiety, partner anxiety, erectile dysfunction, etc.). However, clinicians need to be cognizant that many of the medications we utilize to treat cardiac disease, and those necessary to treat concomitant comorbid conditions, can also significantly affect sexual function. These include
blocking agents, diuretics, antihypertensive medications, sedatives, calcium channel blockers, etc. It is important for the clinician to routinely review the medication regimen to determine if medications are contributing to sexual dysfunction. This is particularly important in patients who may be taking multiple medications, as is commonly the case in cardiac patients.
Increasingly, cardiac patients are asking their physicians to prescribe sildenafil to improve sexual function. Sildenafil is an oral phosphodiesterase inhibitor that induces smooth muscle relaxation allowing erectile tissue to fill with blood, causing an erection.
Sildenafil has been shown to be effective in men with hypertension, diabetes, and other nonvascular erectile dysfunction. It produces a transient reduction in both systolic and diastolic blood pressure (5-10 mm Hg) approximately 1 hour after the dose. Because of the possibility of inducing significant hypotension, particularly in patients taking nitrates or other drugs that may affect blood pressure, or the precipitation of ischemia in previously inactive patients, guidelines have been established.
The guidelines recently issued by the American Heart Association/American College of Cardiology suggest the use of caution: 1) when prescribing sildenafil to patients with active ischemia, significant heart failure, or low blood pressure; 2) for patients receiving multi-drug antihypertensive regimens; and 3) for patients who have compromised liver or kidney function or who are taking drugs such as cimetidine or erythromycin.
Patients who are taking long-acting nitrates should not be given sildenafil due to the risk of significant hypotension. If a patient who has taken sildenafil within the last 24 hours presents with acute MI or an acute coronary syndrome, they should be treated supportively, with pressors if necessary, and alternative anti-ischemia medications such as
blockers should be utilized. Nitrates should be avoided.
In summary, in counseling patients with cardiac disease regarding sexual activity, advice must be individualized. In general, if patients are stabilized, they may resume normal sexual activity within 2-6 weeks. A graded ETT may be of value in higher-risk patients. The clinician must be alert to potential medication effects that may be a contributing factor to sexual dysfunction. Patients should be warned of symptoms with sexual activity that should generate evaluation, i.e., palpitations, shortness of breath, angina, fatigue, etc., and alert their physician should these occur. Finally, the physician should be proactive in assessing and counseling patients regarding sexual functioning. Referral to a cardiac rehabilitation program may be extremely beneficial, not only as secondary prevention, but in helping patients achieve improved quality of life.
Coronary heart disease is the major cause of morbidity and mortality in the elderly population in the United States, affecting both men and women. Advances in cardiac therapies have enabled cardiac patients to remain both physically and sexually active even into their eighties and nineties. However, both patients and physicians are reluctant to discuss sexual issues. A significant number of patients will have sexual dysfunction following a diagnosis of cardiovascular disease. It is therefore imperative that physicians initiate discussions regarding sexual activity and potential risks to the patient such as myocardial infarction, sudden death, and arrhythmia. Risk stratification based on objective criteria and in particular cases, functional testing, may be useful in counseling patients regarding individual risk. Newly available pharmacologic therapies such as sildenafil may be useful, but must be used with caution in patients with known cardiovascular disease.
It has been estimated that in the next decade the number of adults, particularly aged adults, will outnumber children and younger individuals. Cardiovascular disease manifests as a function of increasing age. Advances in health care and therapies are allowing individuals to remain active into their eighties and nineties, and this includes sexual activity. However, sexual problems are common in a large portion of the cardiac patient population. It is therefore important for the clinician to know how to counsel patients who may be at increased risk for cardiac events regarding the relative risks of sexual activity, and to be knowledgeable about the effects of new pharmacologic therapies. It is imperative that clinicians provide explicit advice about sexual activity, particularly to patients with known cardiac disease. Patients are often reluctant to address this issue (as are some physicians). Reassurance based on risk assessment, and in some cases functional testing, may allow patients to continue normal sexual activity after cardiac diagnoses.
Sexual activity may be to some degree equated to other physical exertion, e.g., walking, lifting, light housework. Additional hemodynamic changes may be related to psychological factors such as apprehension, fear, or sexual activity with an unfamiliar partner. In general, for most individuals, it appears that sexual activity is similar to mild to moderate intensity exercise; this is true for individuals with or without coronary disease. Heart rates rarely exceed 130 beats/min and systolic blood pressures are generally less than 170 mm Hg. However, there is some individual variation, based on age and general physical conditioning, with some patients attaining heart rates up to 180 beats/min with orgasm (healthy young volunteers without known heart disease). It has also been documented that in patients with known coronary artery disease, sexual activity may provoke increased arrythmia.
In comparing sexual activity with other forms of activity, the most commonly used clinical measure is the MET, or metabolic equivalent of energy expenditure. For comparison, walking at 2 mph on level ground would equate to 2 METs; walking at 3 mph, 3 METs. Sexual activity preorgasm averages 2-3 METs; sexual activity during orgasm 3-4 METs. Compared to higher-intensity physical exertion, such as cycling at 10 mph (6-7 METs) or walking to stage 4 of a Bruce protocol on the treadmill (13 METs), this exertion is relatively modest.
There appear to be differences in energy expenditure during different types of sexual activity: self-stimulation, partner stimulation, and coitus with man on top and coitus with woman on top. Again, significant variability exists, but on average, in healthy young volunteers, peak heart rate was greater for man on top coitus than with woman on top (heart rate 127±23 vs. 110±24). In metabolic expenditure, this would translate to 2.0-5.4 METs for man on top coitus vs. 2.5-3.0 METs for woman on top coitus. This is compared to peak heart rates of 102±14 for noncoital activity.
Following a cardiac diagnosis (angina, myocardial infarction (MI), congestive heart failure (CHF), significant arrhythmia) or cardiac procedure such as coronary artery bypass, coronary interventional procedure, automatic implantable cardioverter/defibrillator (AICD) placement or cardiac transplant, it has been estimated that approximately 25% of patients return to the previous level of sexual function, 25% do not resume any sexual activity, and 50% return to sexual activity at a reduced level. This varies depending on cardiac condition, with more bypass patients returning to their previous level of function than those post-MI or with angina. Immediately following percutaneous transluminal coronary angioplasty, there appeared to be a less negative impact on sexual function than with bypass surgery; however, at 15 months there was no significant difference. With other cardiac procedures, i.e., cardiac transplantation, pacemaker placement, or AICD implantation, approximately 50% of patients reported no change in sexual activity, with about a 30% improvement in the transplant population, a 41% worsening in reported sexual functioning in the AICD population, and a very modest improvement, approximately 8%, in the pacemaker group.
The reasons generally stated are fear of death, fear of repeated event (i.e., MI, arrhythmia, or cardiac decompensation), fear on the part of a spouse of inducing an event, etc.
It should be emphasized that coital death is a rare event, with only 0.6% of sudden death cases attributable to sexual intercourse. In evaluating risk of MI associated with intercourse, it has been estimated that fewer than 1% of MIs occur during sexual activity. Although sexual activity can trigger MI, the relative risk is low with a slight increase in risk within 2 hours of sexual activity. However, even in high-risk individuals with previous MI the annual risk is 1.10% vs. 1.0% in the population at large. This risk appears to apply equally to men and women.
Patients can therefore be risk stratified and counseled about safely returning to or continuing sexual activity. Those considered low risk would be asymptomatic patients with fewer than three risk factors for coronary artery disease, stable angina, recent uncomplicated MI, mild valvular heart disease, mild CHF, controlled hypertension, or post successful revascularization. These patients can generally be managed medically and followed at regular intervals.
Intermediate risk patients would include those with more than three risk factors for coronary artery disease, recent MI, moderate CHF (New York Heart Association class II), peripheral vascular disease, etc. These patients may benefit from functional testing, i.e., exercise treadmill tests (ETT), echocardiography, or nuclear imaging studies with restratification based on results of testing. ETT can assist in gauging cardiac risk of sexual activity, both for induction of ischemia or arrhythmia. In general, if a patient can achieve 5 METs on ETT without demonstrable ischemia or significant arrhythmia, they are generally not at high risk to resume normal sexual activities. Similarly, if echocardiography does not yield evidence of more than moderate left ventricular dysfunction, resumption of sexual activity is probably safe.
High-risk patients would be those with unstable angina, poorly controlled hypertension, severe CHF (New York Heart Association class III/IV), MI within 2 weeks, significant arrhythmias, severe cardiomyopathies, and moderate to severe valvular disease. These patients should be referred for cardiovascular evaluation and stabilization prior to recommending resumption of sexual activity.
Many factors can interfere with return to sexual activity following cardiac events (fear of death, performance anxiety, partner anxiety, erectile dysfunction, etc.). However, clinicians need to be cognizant that many of the medications we utilize to treat cardiac disease, and those necessary to treat concomitant comorbid conditions, can also significantly affect sexual function. These include
blocking agents, diuretics, antihypertensive medications, sedatives, calcium channel blockers, etc. It is important for the clinician to routinely review the medication regimen to determine if medications are contributing to sexual dysfunction. This is particularly important in patients who may be taking multiple medications, as is commonly the case in cardiac patients.
Increasingly, cardiac patients are asking their physicians to prescribe sildenafil to improve sexual function. Sildenafil is an oral phosphodiesterase inhibitor that induces smooth muscle relaxation allowing erectile tissue to fill with blood, causing an erection.
Sildenafil has been shown to be effective in men with hypertension, diabetes, and other nonvascular erectile dysfunction. It produces a transient reduction in both systolic and diastolic blood pressure (5-10 mm Hg) approximately 1 hour after the dose. Because of the possibility of inducing significant hypotension, particularly in patients taking nitrates or other drugs that may affect blood pressure, or the precipitation of ischemia in previously inactive patients, guidelines have been established.
The guidelines recently issued by the American Heart Association/American College of Cardiology suggest the use of caution: 1) when prescribing sildenafil to patients with active ischemia, significant heart failure, or low blood pressure; 2) for patients receiving multi-drug antihypertensive regimens; and 3) for patients who have compromised liver or kidney function or who are taking drugs such as cimetidine or erythromycin.
Patients who are taking long-acting nitrates should not be given sildenafil due to the risk of significant hypotension. If a patient who has taken sildenafil within the last 24 hours presents with acute MI or an acute coronary syndrome, they should be treated supportively, with pressors if necessary, and alternative anti-ischemia medications such as
blockers should be utilized. Nitrates should be avoided.
In summary, in counseling patients with cardiac disease regarding sexual activity, advice must be individualized. In general, if patients are stabilized, they may resume normal sexual activity within 2-6 weeks. A graded ETT may be of value in higher-risk patients. The clinician must be alert to potential medication effects that may be a contributing factor to sexual dysfunction. Patients should be warned of symptoms with sexual activity that should generate evaluation, i.e., palpitations, shortness of breath, angina, fatigue, etc., and alert their physician should these occur. Finally, the physician should be proactive in assessing and counseling patients regarding sexual functioning. Referral to a cardiac rehabilitation program may be extremely beneficial, not only as secondary prevention, but in helping patients achieve improved quality of life.
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