Sex after Acute MI : Tips and trics of the game <br />Dr Praveen pawal & <br />Dr Awadheshkrsharma,<br />Residents<br />Deptt of medicine<br />Maharani LaxmiBai Medical College<br />Jhansi ,UP<br />
introduction<br />Like 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.<br />
Historical View of Sex<br /><ul><li> 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-------</li></ul>sex detrimental to health<br /><ul><li> 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 .</li></ul>No Sex after 50 <br />
Sexual problems<br />Most cases of impotence do not come to light (despite involving 10% of all male population).<br /> Grossly mismanaged by ignorant patients or even doctors.<br />Not all cases of impotence are psychological in origin , Most are eminently curable.<br />
Not Unique in the Elderly<br /><ul><li>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.
20% or more of both sexes have doubts about their sexual adequacy.</li></li></ul><li>In Old Age<br /><ul><li> Frequency of intercourse reduced but at</li></ul> age 56-85, 50% still engaged in regular sex<br /> once a month<br /><ul><li> National Council on Ageing, USA 1998- pleasure in</li></ul> sexual intercourse increased relatively in old age<br /><ul><li> Depends on quality of relationship
Depends on Erectile Dysfunction</li></li></ul><li>Human sexual response cycles are classified into four phases .<br />(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.<br />(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<br />
(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.<br />(4) Resolution: begins immediately after orgasm if there is no additional stimulation. The body returns to its original, nonexcited state.<br />
Cardiac changes during sex<br /><ul><li>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.</li></li></ul><li>Chagne in BP during sex<br />
<ul><li>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)</li></li></ul><li><ul><li>The risk of death during intercourse is very low but is somewhat higher in situation of extramarital affair.</li></li></ul><li>COITAL ANGINA<br /><ul><li>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</li></li></ul><li>Incidence:<br /><ul><li>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</li></li></ul><li>Incidence contd…<br /><ul><li>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
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</li></li></ul><li>HOW STERNUOUS/ADVICE <br /><ul><li>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</li></li></ul><li><ul><li>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</li></li></ul><li>Sildenafil & Nitrates<br /><ul><li>In healthy volunteers, sildenafil produced a modest decrease</li></ul> in blood pressure <br /> ------ 8.4 mmHg systolic<br /> ------ 5.5 mmHg diastolic<br /><ul><li> In patients receiving medication containing nitrates, hypotensive effects of sildenafil can be severe</li></li></ul><li>Recommendation<br /><ul><li>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.</li></li></ul><li>sildena---Avoid in<br /><ul><li>Myocardial infarction, stroke, or life threatening arrhythmia in the last 6months
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</li></li></ul><li>AHA GUIDELINES<br /><ul><li>a) Patients at low risk </li></ul> 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. <br /><ul><li>These patients can be encouraged to resume sexual activity or receive prompt treatment for sexual dysfunction. </li></li></ul><li><ul><li>b) Patients at intermediate risk: </li></ul> 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). <br /><ul><li>These patients should undergo a thorough cardiac evaluation before resuming sexual activity. </li></li></ul><li><ul><li>c) Patients at high cardiovascular risk: </li></ul> Unstable or refractory angina, uncontrolled hypertension, NYHA class III-IV CHF, recent AMI (<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.<br /><ul><li>They must obtain the cardiologist's clearance before resuming normal sex life, because risk may outweigh benefit.</li></li></ul><li>Final Words<br /><ul><li>Elderly generation was brought up in a different culture.We will venture into the uncharted territories.