Sex after Acute MI : Tips and trics of the game Dr Praveen pawal & Dr Awadheshkrsharma,ResidentsDeptt of medicineMaharani LaxmiBai Medical CollegeJhansi ,UP

introductionLike most everybody else, people with heart disease spend a lot of time thinking about sex. But if your heart's in trouble, those thoughts can turn dark. You may worry that sex can kill you. You may also wonder what happened to your desire. If heart trouble has cast a shadow over your sex life, talk to your doctor. With a little help and reassurance, many people with heart disease can lead full, satisfying lives -- sex included.

Historical View of Sex When scientists studied sexuality in the eighteen century, they did so predominantly in terms of biology When sex no longer has a biological function, the scientists concluded-------sex detrimental to health In the 19th century, doctors recommended that in order to have a long life, men and women alike past age 50 should not have sex .No Sex after 50

When scientists studied sexuality in the eighteen century, they did so predominantly in terms of biology When sex no longer has a biological function, the scientists concluded-------

In the 19th century, doctors recommended that in order to have a long life, men and women alike past age 50 should not have sex .

Sexual problemsMost cases of impotence do not come to light (despite involving 10% of all male population). Grossly mismanaged by ignorant patients or even doctors.Not all cases of impotence are psychological in origin , Most are eminently curable.

Not Unique in the Elderly30% of all males and 40% of all females sometimes lack sexual desire. 37% of college students have trouble occasionally getting an erection or getting lubricated. 30% or more of sexually active college women don't orgasm regularly. 23% of college students ejaculate too soon. 20% or more of both sexes have doubts about their sexual adequacy.

30% of all males and 40% of all females sometimes lack sexual desire.

37% of college students have trouble occasionally getting an erection or getting lubricated.

30% or more of sexually active college women don't orgasm regularly.

23% of college students ejaculate too soon.

20% or more of both sexes have doubts about their sexual adequacy.

In Old Age Frequency of intercourse reduced but at age 56-85, 50% still engaged in regular sex once a month National Council on Ageing, USA 1998- pleasure in sexual intercourse increased relatively in old age Depends on quality of relationship Depends on availability of partners Depends on Erectile Dysfunction

Frequency of intercourse reduced but at

National Council on Ageing, USA 1998- pleasure in

Depends on quality of relationship

Depends on availability of partners

Depends on Erectile Dysfunction

Human sexual response cycles are classified into four phases .(1) Excitement: an increasing level of muscle tension, a quickened heart rate, rise in BP,flushed skin, hardened or erect nipples and the onset of vasocongestion, resulting in swelling of the woman's clitoris and labia minora and erection of the man's penis.(2) Plateau: there are very powerful surges of sexual tension or pleasure in this stage. The intensification of all the changes such that the woman's clitoris may become so sensitive that it is painful to the touch. It extends to the brink of orgasm in man and woman

(3) Orgasm: the shortest phase of the sexual response cycle, typically lasting only several seconds. Usually a man experiences orgasm and ejaculation whereas a woman orgasms, the uterus and orgasmic platform contract in rhythmic waves of muscular movement.HR and BP rises maximally.(4) Resolution: begins immediately after orgasm if there is no additional stimulation. The body returns to its original, nonexcited state.

Cardiac changes during sexThe mean BP at coital equivalent HR is 162/89 mmHg and the mean value of body oxygen consumption was 16 mlO2/min/kgHR during sexual activity might reach 140-180 bpm, SBP increased by 80 mmHg and DBP by 50 mmHg on average.The highest metabolic expenditure at plateau or orgasm was associated with coitus, especially the man-on-top position, where 3 to 4 metabolic equivalents (METs) were exerted.

The mean BP at coital equivalent HR is 162/89 mmHg and the mean value of body oxygen consumption was 16 mlO2/min/kg

HR during sexual activity might reach 140-180 bpm, SBP increased by 80 mmHg and DBP by 50 mmHg on average.

The highest metabolic expenditure at plateau or orgasm was associated with coitus, especially the man-on-top position, where 3 to 4 metabolic equivalents (METs) were exerted.

Chagne in BP during sex

Changes in HR during sex

Sexual intercourse does require energy and causes heart rate and BP to riseSexual activity is often equal to 2 to 3 METS in preorgasmic phase and 3 to 4 METS in orgasmic phase Duration of exposure to increase risk is 2 hrsRecent MI <2 weeks carries high risk of cardiac ruptre, reinfarction & arrhythmias are common.Most of patients able to resume sexual activity within 4 weeks. The position of pt does not make great difference in amount of demand on heart(bottom vs top)

Sexual intercourse does require energy and causes heart rate and BP to rise

Sexual activity is often equal to 2 to 3 METS in preorgasmic phase and 3 to 4 METS in orgasmic phase

Duration of exposure to increase risk is 2 hrs

Recent MI <2 weeks carries high risk of cardiac ruptre, reinfarction & arrhythmias are common.

Most of patients able to resume sexual activity within 4 weeks.

The position of pt does not make great difference in amount of demand on heart(bottom vs top)

The risk of death during intercourse is very low but is somewhat higher in situation of extramarital affair.

The risk of death during intercourse is very low but is somewhat higher in situation of extramarital affair.

COITAL ANGINACoital angina appears to represent less than 5% of all anginal attacks. Sexual activity is often equated with an exercise workload of 2 to 3 metabolic equivalents of task (METS) in the pre-orgasmic phase and 3 to 4 METS in the orgasmic phase.Coital angina is rare in those patients who do not have angina during strenuous physical exertion. It is more prevalent in sedentary individuals with severe coronary disease who experience angina with minimal physical exertionCan manage with pre coital NTG

Coital angina appears to represent less than 5% of all anginal attacks. Sexual activity is often equated with an exercise workload of 2 to 3 metabolic equivalents of task (METS) in the pre-orgasmic phase and 3 to 4 METS in the orgasmic phase.

Coital angina is rare in those patients who do not have angina during strenuous physical exertion. It is more prevalent in sedentary individuals with severe coronary disease who experience angina with minimal physical exertion

Can manage with pre coital NTG

Incidence:Literature data show that erectile dysfunction is highly prevalent at time of AMI, affects 24% to 89% of the patients.It is estimated that 10 to 15% patients are sexually impotent & 40 to 70% of coronary patients have lower frequency of sexual activityLess than 1% MI occur during sexual activity, the relative risk of MI is 2.5 times grater than during non coital activitiesThe duration of exposure to the increased risk appears to be 2 hours following coitus

Literature data show that erectile dysfunction is highly prevalent at time of AMI, affects 24% to 89% of the patients.

It is estimated that 10 to 15% patients are sexually impotent & 40 to 70% of coronary patients have lower frequency of sexual activity

Less than 1% MI occur during sexual activity, the relative risk of MI is 2.5 times grater than during non coital activities

The duration of exposure to the increased risk appears to be 2 hours following coitus

Incidence contd…Patients' knowledge, frequency of sexual activity prior to AMI and expectations regarding sex after hospital discharge is important.4% showed a good understanding of their disease, while 96% knew nothing about AMI clinical manifestations or its attendant limitationSexual relations prior to the AMI, 63%, 60% expressed interest in resuming their sex life after discharge 44% admitted a decrease in the frequency of sexual relations following the event.

Patients' knowledge, frequency of sexual activity prior to AMI and expectations regarding sex after hospital discharge is important.

4% showed a good understanding of their disease, while 96% knew nothing about AMI clinical manifestations or its attendant limitation

Sexual relations prior to the AMI, 63%,

60% expressed interest in resuming their sex life after discharge

44% admitted a decrease in the frequency of sexual relations following the event.

Sexual activity as a trigger ofMyocardial Infarction?N=699Only 1.3% of patients without premonitory symptoms have sexual activities during 2 hours before onset of myocardial infarct RR 2.1 (CI 0.7-6.5) RR 4.4 (CI 1.5-12.9) patient on sedentary life styleConclusion: absolute risk is low, exposure infrequent 1 in 1 million in low risk 2 in 1 million with sexual activities Counseling should focus on encouraging patients to live a physically active life and not on abstaining from sexual activities

N=699

Only 1.3% of patients without premonitory symptoms have sexual activities during 2 hours before onset of myocardial infarct

RR 2.1 (CI 0.7-6.5)

RR 4.4 (CI 1.5-12.9) patient on sedentary life style

Conclusion: absolute risk is low, exposure infrequent

1 in 1 million in low risk

2 in 1 million with sexual activities

Counseling should focus on encouraging patients to live a physically active life and not on abstaining from sexual activities

In Another StudyMuller et al JAMA 1996 9% of patients had sexual activity in the 24 hours, and 3% in the two hours,preceding myocardial infarctionRR 2 hrs = 2.5Not increased in patients with a history of previous angina pectoris or myocardial infarctionThe absolute risk increase was low, one in a million for a healthy individuaL

Muller et al JAMA 1996

9% of patients had sexual activity in the 24 hours, and 3% in the two hours,preceding myocardial infarction

RR 2 hrs = 2.5

Not increased in patients with a history of previous angina pectoris or myocardial infarction

The absolute risk increase was low, one in a million for a healthy individuaL

HOW STERNUOUS/ADVICE In general, sexual intercourse should be safe if a patient can perform an activity equal to 5-6 metabolic equivalents (METS), such as climbing 20 stairs in 10-15 seconds without distress (or 2-4 Flights without chest pain)Post infarction patients who reach 5-6 METS on stress testing without ischaemia or arrhythmia can resume their normal sexual activity without risk

In general, sexual intercourse should be safe if a patient can perform an activity equal to 5-6 metabolic equivalents (METS), such as climbing 20 stairs in 10-15 seconds without distress (or 2-4 Flights without chest pain)

Post infarction patients who reach 5-6 METS on stress testing without ischaemia or arrhythmia can resume their normal sexual activity without risk

Low-risk patients with erectile dysfunction can be safely treated with a phosphodiesterase type 5 (PDE5) inhibitor.Patients should be cautioned about the contraindication between PDE5 medications and nitrates.Introduction Sexual activity is an important component of quality of life and is of great concern for patients with heart disease and their physician

Low-risk patients with erectile dysfunction can be safely treated with a phosphodiesterase type 5 (PDE5) inhibitor.

Patients should be cautioned about the contraindication between PDE5 medications and nitrates.Introduction Sexual activity is an important component of quality of life and is of great concern for patients with heart disease and their physician

Sildenafil & NitratesIn healthy volunteers, sildenafil produced a modest decrease in blood pressure ------ 8.4 mmHg systolic ------ 5.5 mmHg diastolic In patients receiving medication containing nitrates, hypotensive effects of sildenafil can be severe

In healthy volunteers, sildenafil produced a modest decrease

In patients receiving medication containing nitrates, hypotensive effects of sildenafil can be severe

RecommendationAbsolutely contraindicated inpatients receiving treatment with long-acting nitratesPatients who need sublingual short-acting nitrates infrequently should not be precluded from taking sildenafil, provided they are aware that sildenafil is not to be taken within 24 h of taking the nitrates.

Absolutely contraindicated inpatients receiving treatment with long-acting nitrates

Patients who need sublingual short-acting nitrates infrequently should not be precluded from taking sildenafil, provided they are aware that sildenafil is not to be taken within 24 h of taking the nitrates.

sildena---Avoid inMyocardial infarction, stroke, or life threatening arrhythmia in the last 6monthsResting BP <90/50 mm Hg or >170/110mm HgActive cardiac failure or unstable anginaRequirement for nitrates either chronically or on an as-needed basisComplicated multi-drug antihypertensive regimensRetinitis pigmentosa

Myocardial infarction, stroke, or life threatening arrhythmia in the last 6months

Resting BP <90/50 mm Hg or >170/110mm Hg

Active cardiac failure or unstable angina

Requirement for nitrates either chronically or on an as-needed basis

Complicated multi-drug antihypertensive regimens

Retinitis pigmentosa

Vardenafil(LevitraGlaxo / Bayer2.5-20mg better with empty stomach Onset 15-30min; Half life 4-5 hrsSaid to be 9 fold selectivityProlongation of QT interval Should NOT be used in congenital long QT syndrome or those taking quinidine, procainamide, amiodarone, or sotalol Worsen the hypotensive effect of adrenergic receptor blockers such as doxazosin and terazosin

2.5-20mg better with empty stomach

Onset 15-30min; Half life 4-5 hrs

Said to be 9 fold selectivity

Prolongation of QT interval

Should NOT be used in congenital long QT syndrome or those taking quinidine, procainamide, amiodarone, or sotalol

Worsen the hypotensive effect of adrenergic receptor blockers such as doxazosin and terazosin

Tadalafil 10-20mgLonger duration of action 36hoursCan be taken with food Back pain / myalgia 6%.Avoid blockers

10-20mg

Longer duration of action 36hours

Can be taken with food

Back pain / myalgia 6%.

Avoid blockers

Viagra and MI Phase II-III studies randomized 349 placebo patient-years 693 sildenafil patient-years4220 patient-years in open-label studies Incidence of MI lower in the sildenafil group than in the placebo group (not statistically significant) Incidence of adverse events attributable to lowering of blood pressure in patients taking sildenafil was also low and no higher than in those receiving placebo

Phase II-III studies randomized

349 placebo patient-years

693 sildenafil patient-years

4220 patient-years in open-label studies

Incidence of MI lower in the sildenafil group than in the placebo group (not statistically significant)

Incidence of adverse events attributable to lowering of blood pressure in patients taking sildenafil was also low and no higher than in those receiving placebo

AHA GUIDELINESa) Patients at low risk Asymptomatic; with less than three risk factors for coronary artery disease (CAD) (excluding gender); controlled hypertension; class I or II stable angina of the Canadian Cardiovascular Society (CCS); successful coronary revascularization; history of uncomplicated AMI, mild valvular disease, congestive heart failure (CHF) without left ventricular (LV) dysfunction and/or in NYHA class I. These patients can be encouraged to resume sexual activity or receive prompt treatment for sexual dysfunction.

a) Patients at low risk

These patients can be encouraged to resume sexual activity or receive prompt treatment for sexual dysfunction.

b) Patients at intermediate risk: At least three risk factors for CAD (excluding gender), class II or III stable angina of the CCS classification, recent AMI (from 2 to 6 weeks), left ventricular (LV) dysfunction and/or NYHA class II CHF, noncardiac sequel from atherosclerotic disease (stroke [AVC] and/or peripheral vascular disease). These patients should undergo a thorough cardiac evaluation before resuming sexual activity.

b) Patients at intermediate risk:

These patients should undergo a thorough cardiac evaluation before resuming sexual activity.

c) Patients at high cardiovascular risk: Unstable or refractory angina, uncontrolled hypertension, NYHA class III-IV CHF, recent AMI (&lt;2 weeks); high-risk arrhythmias, severe cardiomyopathies, moderate-to-severe valvular disease. For these patients sexual activity should be delayed until they are stabilized for their heart condition, since it poses a significant risk.They must obtain the cardiologist's clearance before resuming normal sex life, because risk may outweigh benefit.

c) Patients at high cardiovascular risk:

They must obtain the cardiologist's clearance before resuming normal sex life, because risk may outweigh benefit.

Final WordsElderly generation was brought up in a different culture.We will venture into the uncharted territories.Should not hesitate to ask sex history.A small change in drugs,counselling, advice will make big difference in quality of life.

Elderly generation was brought up in a different culture.We will venture into the uncharted territories.

Should not hesitate to ask sex history.

A small change in drugs,counselling, advice will make big difference in quality of life.

STHANK U