Sexual activity is an important component of quality of life and thus is of great concern for both patients with heart disease and their physicians. Cardiac patients are often fearful of triggering myocardial infarction (MI) during intercourse and may therefore have sex less frequently.

1. Sexual activity in patients with
heart disease
HUSSEIN ELKHAYAT,MD
CARDIOTHORACIC SURGERY DEPARTMENT
FACULTY OF MEDICINE
ASSIUT UNIVERSITY,ASSIUT,EGYPT

2. Why we talk about that !!
 Sexual activity is an important component of quality of
life and thus is of great concern for both patients with
heart disease and their physicians
 Cardiac patients are often fearful of triggering
myocardial infarction (MI) during intercourse and may
therefore have sex less frequently.

3. CARDIOVASCULAR EFFECTS
OF SEXUAL ACTIVITY
 Sexual activity, including arousal, erection, ejaculation, orgasm,
refractory period, and resolution, is in part dependent upon
changes in the autonomic nervous system.
 penile erection in men results from stimulation of
parasympathetic nerves in the penis, reduced activity of
sympathetic pathways, and the release of nitric oxide from the
endothelium . The importance of nitric oxide constitutes the
rationale for the use of sildenafil in men with sexual dysfunction.
 Early sexual arousal in women appears to result from
sympathetic nervous system activation

4.  The main outflow to the cardiovascular system during sexual
intercourse is sympathetic and is mediated by outputs from the
brain carried by efferent pathways originating from the thoracic
spinal cord
 Hemodynamic stress …… conflict in early and late reseach

5.  The mean heart rate at the time of orgasm was 117
beats per minute, which was lower than the heart rate
during normal daily activities (mean 120 beats per
minute).
 sexual activity contributes to only a small percent of
infarctions

6. the effect of exercise training and sexual
position on the cardiovascular response to
sexual activity
 Exercise training attenuates the heart rate response
and reduces the small risk of MI following sex
 It has been assumed that the man would perform less
physical work during sexual intercourse if he were
supine. However, this does not appear to be
important.

7. Response in stable angina
 During sexual intercourse, the increase in heart rate and blood
pressure is the same as any form of exercise. Thus, patients with
angina may become symptomatic during intercourse
 Appropriate medical therapy can prevent angina in these
patients and permit a normal sex life
 Patients with chronic coronary disease who undergo
revascularization with a percutaneous coronary intervention or
bypass surgery and who are asymptomatic do not have an
increased risk of symptoms during sexual intercourse.

8. RISK OF MI AFTER SEX
 The relative risk of MI within two hours after sexual
activity was 2.5; there was no increased risk of MI
beyond this time period. The risk was reduced in
patients who underwent regular exercise.
 sexual activity appeared to contribute to the onset of
MI in only 0.9 percent of patients. Many other triggers
of an MI, such as psychologic stress, anger, or physical
activity may cause a greater increase in absolute risk
because they occur more frequently

9. Modulation of risk
 Two factors appear to modulate the risk of MI after
intercourse:
 exercise and
 medical therapy.

10. RISK OF SEXUAL ACTIVITY
 Low risk — The large majority of patients are at low risk. This includes patients
with:
 No symptoms and less than three cardiovascular risk factors (excluding gender)
 Controlled hypertension
 Mild, stable angina, although the antianginal regimen may need to be altered (ie,
no nitrates) in patients who are treated with a phosphodiesterase-5 inhibitor for
erectile dysfunction
 Successful coronary revascularization
 An MI more than six to eight weeks previously in patients who are asymptomatic
and do not have exercise-induced ischemia or have undergone coronary
revascularization; it is probably safe to resume sexual activity three to four weeks
after the MI in patients who have undergone successful revascularization and in
patients without exercise-induced ischemia
 Mild valvular disease
 Patients at low risk can be safely encouraged to initiate or resume sexual activity
and can be treated for sexual dysfunction.
 There are limited data on patients with pericarditis, mitral valve prolapse, or atrial
fibrillation with a controlled ventricular response. These patients are not at high
risk and should be managed on an individualized basis

11.  Intermediate or indeterminate risk — Intermediate risk includes patients with:
 No symptoms and three or more cardiovascular risk factors (excluding gender); a
sedentary lifestyle is considered a risk factor
 Moderate, stable angina
 A recent MI (more than two weeks but less than six weeks); as noted above, in
patients who have not undergone revascularization, the risk can be assessed with
stress testing, which is often performed during this period
 Asymptomatic left ventricular dysfunction with left ventricular ejection fraction <40
percent or New York Heart Association class II heart failure
 Noncardiac manifestations of atherosclerotic disease, such as peripheral vascular
disease or prior stroke or transient ischemic attack.
 Patients at intermediate or indeterminate risk should receive further evaluation,
as stress testing, particularly in patients with a sedentary lifestyle, which may permit
restratification into the low risk or high risk category. Consultation with a
may be useful in some cases for assessing risk and management.

12.  High risk — High risk includes patients with:
 Unstable or refractory angina
 Uncontrolled hypertension
 New York Heart Association class III or IV heart failure
 An MI within the past two weeks
 High-risk arrhythmias
 Obstructive hypertrophic cardiomyopathy
 Moderate-to-severe valvular disease, particularly aortic
stenosis
Patients at high risk should be stabilized by appropriate
therapy and further risk stratified before resuming sexual
activity.

13. SEXUAL DYSFUNCTION
POST-MI
 Sexual dysfunction is common in patients with cardiovascular
disease because of concern about risk; side effects of
medications (diuretics, beta blockers, lipid-lowering drugs); the
coexistence of shared risk factors, such as lipid abnormalities,
diabetes, smoking, and hypertension; and the presence of
psychologic factors.
 Sexual dysfunction after an MI (most often erectile dysfunction
in men) is estimated to occur in one-half to three-quarters of
patients; although less common, sexual dysfunction is also seen
after bypass surgery

14.  Cardiac patients may have psychologic causes for sexual
dysfunction, which are often due to perceptions of their illness
and should be ascertained in the history.
 Worries about triggering an MI or sudden death and depression
and anxiety about a newly diagnosed illness, especially the
occurrence of an MI, can all contribute to sexual dysfunction in
patients with heart disease

15. TREATMENT OF SEXUAL
DYSFUNCTION
 General principles — The management of sexual dysfunction in
patients with cardiovascular disease is based in part upon the
estimated risk as described above

16.  Low risk — Such patients can be safely encouraged to initiate or
resume sexual activity or to receive treatment for sexual
dysfunction.
 Intermediate risk — Such patients should receive further
evaluation in order for restratification into a low risk or high risk
category. This is often achieved by stress testing, particularly in
patients with a sedentary lifestyle. Consultation with a cardiologist
may be useful in some cases for assessing risk and management.
 High risk — Such patients should be stabilized by appropriate
therapy and further risk stratified before resuming sexual activity
or being treated for sexual dysfunction.

17.  An important component of the treatment of sexual dysfunction
in all patients is correction of reversible causes. In patients with
heart disease, this includes reassurance in patients in whom
sexual activity is considered to be safe and drug-induced side
effects.

18.  Among the cardiovascular drugs that may be implicated are
thiazide diuretics, beta blockers, and lipid-lowering drugs.
 Consideration should be given to the time sequence of initial
symptoms and changes in a patient's medications, and, when
possible, alternative prescriptions should be pursued.
 phosphodiesterase-5 (PDE-5) inhibitors should not be used with
nitrates in any form

19.  PDE-5 inhibitors — The phosphodiesterase-5 (PDE-5) inhibitors
sildenafil, vardenafil, and tadalafil are widely used in the
treatment of erectile dysfunction in men and can have
effects in patients with heart disease. Most of the published data
is related to the use of sildenafil

20.  Sildenafil — Sildenafil can improve erectile function in patients
with stable ischemic heart disease. This was illustrated in a report
of 357 men with stable chronic coronary heart disease in whom
sildenafil improved erection in 70 percent compared to 20 percent
with placebo
 Sildenafil is also effective in men with hypertension, diabetes, and
nonvascular organic or psychogenic causes for erectile

21.  Sildenafil has two important cardiovascular actions in
patients with heart disease: it can lower the blood
pressure and it can interact with nitrates . Sildenafil is a
vasodilator that reduces systemic vascular resistance. It
lowers the systolic pressure by about 8 mmHg, an
effect that is not more pronounced when given with
antihypertensive drugs that also have vasodilator
activity

22.  Sildenafil also dilates epicardial coronary arteries and, in patients
with coronary heart disease, improves endothelial dysfunction and
inhibits platelet activation. Among patients with exercise-induced
ischemia, sildenafil has a beneficial effect that is intermediate
between that induced by isosorbide dinitrate and placebo

23. Thank you
This lecture is based on uptodate.com CME course about sexual
activity in patients with heart disease.