Talking about sex for many people is embarrassing, awkward and downright difficult, especially when one of the partners is having a problem.
Heart patients and their partners have the added burden of fearing for the patient’s health. Now, people with cardiovascular disease (CVD) have current evidence — and scientific-based guidelines — to help them understand when sexual activity is safe, when endurance testing is needed, and when the risks outweigh the benefits. The key, however, is getting patients and physicians to talk openly and honestly about this delicate subject.
“Sexual intimacy is a significant quality-of-life issue for heart patients and their partners,” said Perry J. Weinstock, MD, FACC, Head, Division of Cardiovascular Disease and Director of Clinical Cardiology at Cooper University Hospital. “A decrease in sexual activity and function often leads to anxiety and depression, which can ultimately increase cardiac risk.”
Knowing When Sexual Activity Is Safe
The American Heart Association recently published updated guidelines that were endorsed by the American Urological Association, the Society for Thoracic Surgeons, the International Society for Sexual Medicine and many other professional societies. The document provides recommendations for when sex is safe and strongly encourages physicians to have “the talk” with patients.
The writing committee included cardiologists from across the country and only one urologist, Cooper’s Allen D. Seftel, MD, FACS, Head of Urology, a world-renowned sexual health expert and Chairman of the American Urologic Association Foundation’s Outreach Council.
“We provided guidance that sex is safe under the right conditions in the appropriate patient,” said Dr. Seftel. “The risk of adverse cardiac events during sexual encounters and shortly thereafter is extremely low when the patient’s heart condition is well managed and the patient is able to tolerate light-to-moderate exercise.”
Light-to-moderate exercise is the ability to climb stairs without experiencing chest pain or discomfort. Medical terminology refers to this activity as METs, the “metabolic equivalent of a task” or the amount of energy consumed during a specific physical activity. One MET is defined as “the basal amount of oxygen consumed while seated at rest.” Climbing a flight of stairs equals approximately four METs.
According to Dr. Seftel, the rate of cardiovascular events before, during or after sexual activity is miniscule because exposure to sexual activity is of short duration and the greatest risk occurs during orgasm, which typically lasts 10 to 15 seconds.
A Difficult Topic
“I find that men are most reluctant to discuss sexual issues,” noted Dr. Weinstock. “The topic often comes up in a round-about way, when a male patient says ‘Oh by the way’ or ‘My stamina isn’t what it used to be.’ In many cases, the wife gives her husband a nudge by asking, ‘Isn’t there something else we should talk about?’
“In the privacy of an exam room, patients should feel comfortable talking about anything,” said Dr. Weinstock, who encourages patients to discuss their sexual health with their physicians. “Very few patients come right out and ask about issues with sexual activity even though it is a normal and very important part of life for both the patient and the partner.”
When there is a problem with erectile dysfunction (ED), for example, Dr. Weinstock usually refers patients to Dr. Seftel to examine the potential causes and treatment options for the sexual dysfunction. And when Dr. Seftel is treating men with ED, he often sends them to Dr. Weinstock for a full cardiovascular workup, including stress testing.
“We have identified undetected cardiovascular disease in young men with ED,” said Dr. Seftel, who is also the author of one of the many studies that have identified the correlation with ED and future risk for cardiac disease in men as young as their early-to mid-40s. “The AHA’s guidelines are now opening the door for physicians and patients to initiate this conversation.”
The AHA Guidelines indicate that sexual activity is safe for patients with:
- CVD that is determined to be at low risk of cardiovascular complications.
- Coronary artery disease with no or mild angina.
- Compensated and/or mild heart failure.
- Mild or moderate valvular heart disease and no or mild symptoms.
- Normally functioning prosthetic valves, successfully repaired valves, and successful transcatheter valve interventions.
- Atrial fibrillation or atrial flutter and well-controlled ventricular rate.
- A history of atrioventricular nodal reentry tachycardia, atrioventricular reentry tachycardia, or atrial tachycardia with controlled arrhythmias.
- Pacemakers, an ICD implanted for primary prevention, as well as people with an ICD used for secondary prevention and who can tolerate moderate physical activity that does not precipitate ventricular tachycardia or fibrillation and who do not receive frequent multiple appropriate shocks.
- Congenital heart disease (CHD) who do not have decompensated or advanced heart failure, severe and/or significantly symptomatic valvular disease, or uncontrolled arrhythmias.
- Hypertrophic cardiomyopathy (without symptoms).
The AHA recommends deferring sexual activity or stress testing for patients:
- Who are not at low cardiovascular risk or have unknown cardiovascular risk to assess exercise capacity and development of symptoms, ischemia, or arrhythmias.
- With incomplete coronary revascularization, exercise stress testing is needed to assess the extent and severity of residual ischemia.
- With severe or significantly symptomatic valvular disease until their condition is stabilized and optimally managed.
- With atrial fibrillation and poorly controlled ventricular rate, uncontrolled or symptomatic supraventricular arrhythmias, and spontaneous or exercise-induced ventricular tachycardia until the condition is optimally managed.
- With an ICD who have received multiple shocks until the causative arrhythmia is stabilized and optimally controlled.
- With hypertrophic cardiomyopathy who are severely symptomatic until their condition is stabilized.
The AHA recommends avoiding sex following cardiac events or procedures:
- One or more weeks after uncomplicated myocardial infarction (heart attack) if the patient is without cardiac symptoms during mild to moderate physical activity.
- Several days after percutaneous coronary intervention (PCI) if the vascular access site is without complications.
- Six to eight weeks after noncoronary open heart surgery provided the sternotomy is well healed.
AHA recommendations for PDE5inhibitors – Cialis®, Levitra®, Viagra®:
- Stable cardiovascular disease.
- The safety of PDE5s is unknown in patients with severe aortic stenosis or hypertrophic cardiomyopathy (HCM).
- PDE5s should not be used in patients receiving nitrate therapy.
Heart patients should be very cautious and consult their physician before taking any over-the-counter (OTC) medications or supplements designed to treat erectile dysfunction or increase sexual arousal. Most physicians advise patients not to take any herbal supplements or OTC medications designed to cure ED or enhance sexual function.
“Remember, if you or your partner has any concerns, please ask your doctor. Once you get started, the conversation will flow and you can dramatically improve the quality of both of your lives,” Dr. Seftel said.