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Sexual activity after myocardial infarction

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This presentation describes cardiovascular risk of sexual activity as well as recommendation to manage erectile dysfunction in men with coronary artery disease

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Sexual activity after myocardial infarction

  1. 1. Sexual Activity AfterMyocardial Infarction Tarek Anis, M.D. Prof. of Andrology, Cairo University
  2. 2. Cardiovascular Aspects of Sexual Medicine The 3rd International Consultation on Sexual Medicine, Paris 2010 Graham Jackson Piero Montorsi Tarek Anis Michael A Adams Ahmed El-Sakka Martin Miner Charalambos Vlachopoulos Edward Kim
  3. 3. Cardiovascular DiseaseStatistics in the Middle East
  4. 4. Cardiovascular Disease Statistics in the Middle EastWorld Health Organization estimates that 17.5 million peoplearound the globe die of CVDs each year, representing 30%of all deaths world wide.CVDs are no longer diseases of the developed world. About80% of CVD deaths took place in low- and middle-incomecountries. CVDs are the leading cause of death in thosecountries.At least 20 million people survive heart attacks every year.For those patients and their partners, sexual activity is animportant component of life. World Health Organization (WHO) estimates, in 2006
  5. 5. Cardiovascular Disease Statistics in the Middle East The World Health Organization estimates indicate that there is a marked increase of cardiovascular deaths in most countries from the Middle East region compared with data from western countries, particularly from ischemic heart disease and hypertensive heart disease The median age at presentation with myocardial infarction is 51 years in the Middle East; this is lower than the median age at presentation in nine other regions, and is 12 years lower than the median age at presentation in Western EuropeYusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries(the INTERHEART study): case-control study. Lancet. 2004;364: 937–952.
  6. 6. Current Death Rates from Cardiovascular Disease in the Middle East Deaths per 100,000 World Health Organization. Data and statistics: mortality and health status. Available from: http:// www.who.int/research/en/. Accessed January 12, 2012
  7. 7. Knowing that the projected increase in coronary deaths between 1990 and 2020 in the established marketeconomies is 46%, what do you think it would be in the Middle East ? 1) About the same 2) 92 % (2 times) 3) 138 % (3 times) 4) 171 % (almost 4 times)
  8. 8. Projected Increase in Coronary Deaths between 1990 and 2020 200 171% 150 144% 144%% increase 127% 108% 100 50 46% 0 Middle America India China sub- Latin East & Europe Saharan America Africa Okrainec K, Banerjee DK, Eisenberg MJ. Coronary artery disease in the developing world. Am Heart J. 2004;148:7–15.
  9. 9. Prevalence of Diabetes Source : International Diabetes Federation
  10. 10. Prevalence of Diabetes 6 of the top 10 countries 19.5%20 16.7% 15.2% 14.4%15 13.1% 11%1050 U.A.E Saudi Arabia Bahrain Kuwait Oman Egypt
  11. 11. Trends in Total Cigarette Consumptionin Eastern Mediterranean and Americas Guindon DE, Boisclair G. World Health Organization Tobacco Free Initiative. Past, Current and Future Trends in Tobacco use. HNP discussion paper series; economics of tobacco control paper no. 6 (2003). Available from: http://siteresources.worldbank.org/H
  12. 12. Prevalence of Obesity Source : International Diabetes Federation
  13. 13. The Relation betweenErectile Dysfunction andCardiovascular Diseases
  14. 14. The Prevalence of EDED is a remarkably 80 77.6common condition. 60.2 60 43.7 40 23.9ED in a substantial 20 6.5 3.8 8.2majority of men is 0 20-29 30-39 40-49 50-59 60-69 70-74 >75due to underlying n=2536, ED 18.5 %vascular causes. Associations Between ED and Various Comorbid States 100%ED is highly 90% 80% 70%prevalent in men 60% 50% 40% 49% 52% 30% 35%with vascular risk 20% 10% 0% 24% 15%factors for CVD. Diabetes mellitus Obesity Heart disease Hypertension Smoking Christopher S Saigal, Hunter Wessells, Jennifer Pace, Matt Schonlau, Timothy J Wilt. Predictors and prevalence of erectile dysfunction in a racially diverse population. Arch Intern Med. 2006;166:207-212
  15. 15. Risk Factors of EDTraditional Underlying EmergingAge Obesity insulin resistance/High LDL cholesterol Sedentary lifestyle metabolic syndromeLow HDL cholesterol Atherogenic dietHypertensionDiabetesSmoking 1 2 3
  16. 16. Traditional Underlying EmergingAge Obesity insulin resistance/High LDL cholesterol Sedentary lifestyle metabolic syndromeLow HDL cholesterol Atherogenic dietHypertensionDiabetesSmoking 1 2 3
  17. 17. Risk Factors of CVDsTraditional Underlying EmergingAge Obesity insulin resistance/High LDL cholesterol Sedentary lifestyle metabolic syndromeLow HDL cholesterol Atherogenic dietHypertensionDiabetesSmoking 1 2 3
  18. 18. ED is an Indicator for Increased Risk of Coronary Artery DiseaseAnton Ponholzera, Christian Temmlb, Rudolf Obermayrc, Clemens Wehrbergera, Stephan Madersbacher. Is Erectile Dysfunctionan Indicator for Increased Risk of Coronary Heart Disease and Stroke?. European Urology 48 (2005) 512–518
  19. 19. Degree of ED Related to Extent of Coronary Artery Disease Sexual activity in the previous month in with ischemic heart disease Frequency of any 1.2 erection* 2-3 vessles 2.1 Single vessle No of erections 1.2 sufficient for 2.7 penetration 1.8Difficulty achieving erection# 3 0 1 2 3 4 * 0 = not at all, 4 = always # 0 = extreme difficulty (i.e. no erections), 4 = no difficulty Greenstein A., et al. Int J Impot Res, 1997:9123-126
  20. 20. Erectile dysfunction a marker of coronary artery disease1) This is specially true for older patients (above 60)2) This is specially true for younger patients (below 45)3) Age is irrelevant
  21. 21. Incidence of Coronary Artery Disease with Respect to Age and Erectile Dysfunction Status ED No ED Incidence per 1000 person-years 48.52 29.63 27.15 23.97 23.3 10.72 5.09 0.94 40-45 50-59 60-69 ≥ 70 AgeInman BA, Sauver JL, Jacobson DJ, McGree ME, Nehra A, Lieber MM, Roger VL, Jacobsen SJ. A population-based,longitudinal study of erectile dysfunction and future coronary artery disease. Mayo Clin Proc 2009; 84 (2): 108-13.
  22. 22. Why We Do not see EDPatients in Cardiology Clinics?
  23. 23. Cardiovascular Patients self-addressing ED with their Cardiologist No of Patients Estimated No with ED Talked about ED 9% 0% 0% Western Europe Middle East USSchwarz et al,. A multidisciplinary approach to assess erectile dysfunction in high-risk cardiovascular patients International Journal ofImpotence Research Volume 17, Issue S1 (December 2005)
  24. 24. Cardiovascular patients admitting ED with their cardiologist (physician addressed) No of Patients Estimated ED Admitted ED Rx for ED 81% 83% 75% 32% 35% 28% Western Europe Middle East US Schwarz et al,. A multidisciplinary approach to assess erectile dysfunction in high-risk cardiovascular patients International Journal of Impotence Research Volume 17, Issue S1 (December 2005)
  25. 25. Acute Cardiovascular Effects of Sexual Activity
  26. 26. Energy requirement during sexualactivity to orgasm equals that spent during1) Walking at 2 mph2) Climbing 2 flights of stairs3) Cycling at 10 mph4) Walking at 4.2 mph and 16% Grade
  27. 27. Energy Requirements (METS) of Selected Physical Activities Walking 2 mph, level 2 Walking 3 mph, level 3 Sexual Activity, pre-orgasm 2-3 Sexual Activity, during orgasm 3-4 Climbing 2 flights of stairs 3-4 Cycling 10 mph, level 6-7 Walking 4.2 mph, 16% Grade 13 (Bruce treadmill stage 4) DeBusk RF. Am J Cardiol. 2000;86(suppl 1):51F-56F.
  28. 28. Physiological Responses during Heterosexual Vaginal Intercourse During foreplay, systolic and diastolic systemic blood pressure and heart rate increase mildly More modest increases during sexual arousal. The greatest increases occur during the 10 to 15 seconds of orgasm (Heart rate rarely exceeds 130 bpm and systolic blood pressure rarely exceeds 170 mm Hg in normotensive individuals), with a rapid return to baseline. Men and women have similar responsesLevine et al., Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation2012; 125 (8): 1058-72.
  29. 29. Acute Cardiovascular Effects of Sexual ActivitySexual activity in young healthy married men with hisusual partner is comparable to mild to moderate physicalactivity in the range of 3 to 4 METS (≈ of climbing 2 flightsof stairs or walking briskly for a short duration).This may not characterize all individuals, especially thosewho are older, are less physically fit, or have CVDSome patients, particularly older people, may havedifficulty reaching an orgasm for medical or emotionalreasons and may exert themselves to a greater degree ofexhaustion with relatively greater demand on theircardiovascular systemLevine et al., Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation2012; 125 (8): 1058-72.
  30. 30. Sexual Activity andCardiovascular Risk
  31. 31. Coital Angina “angina d’amour” Angina that occurs during the minutes or hours after sexual activity, represents 5% of all anginal attacks. It is rare in patients who do not have angina during strenuous physical exertion and more prevalent in sedentary individuals with severe CAD who experience angina with minimal physical activity. If a patient can achieve an energy expenditure of 3 to 5 METs without demonstrating ischemia during exercise testing, then the risk for ischemia during sexual activity is very low.DeBusk RF. Sexual activity in patients with angina. JAMA. 2003;290: 3129–3132.Drory Y. Sexual activity and cardiovascular risk. Eur Heart J Suppl. 2002;4(suppl H):H13–H18.
  32. 32. Sexual Activity and Myocardial Infarction A recent meta-analysis of 4 case-crossover studies, including males in their 50s and 60s, showed that sexual activity was associated with a 2.7 increased relative risk of myocardial infarction, compared with periods of time when the subjects were not engaged in sexual activityDahabreh IJ, Paulus JK. Association of episodic physical and sexual activity with triggering of acute cardiac events:systematic review and meta-analysis. JAMA. 2011;305:1225–1233.
  33. 33. Onset of Myocardial Infarction Following Sexual Activity Although sexual activity is associated with an increased relative risk of cardiovascular events, the absolute rate of events is very low because exposure to sexual activity is of short duration and constitutes a very small percentage of the total time at risk for myocardial ischemia or MI. Sexual activity is the cause of 1% of all acute MIs The absolute risk increase for MI associated with 1 hour of sexual activity per week is estimated to be 2 to 3 per 10 000 person-yearsDahabreh IJ, Paulus JK. Association of episodic physical and sexual activity with triggering of acute cardiac events:systematic review and meta-analysis. JAMA. 2011;305:1225–1233.Mulleret al. Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physicalexertion. Determinants of Myocardial Infarction Onset Study Investigators. JAMA 1996; 275 (18): 1405-9
  34. 34. Onset of MI Following Sexual Activity 858 patients with prior CAD Relative risk of MI onset Time of sexual activity (hours before MI onset)Mulleret al. Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physicalexertion. Determinants of Myocardial Infarction Onset Study Investigators. JAMA 1996; 275 (18): 1405-9
  35. 35. Protective Effect of Regular ExerciseThe risk of MI onset 2 hours following 3 3 858 patients with prior CHD 2.5 2 sexual activity 2 1.5 1.2 Baseline 1 risk 0.5 0 ≤1 2 ≥3 Frequency of physical exertion of ≥ 6 METS Mulleret al. Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical exertion. Determinants of Myocardial Infarction Onset Study Investigators. JAMA 1996; 275 (18): 1405-9
  36. 36. Sexual Activity and Ventricular Arrhythmias/Sudden Death Autopsy studies reported low rates (0.6%–1.7%) of sudden death related to sexual activity. 82% to 93% were men, and the majority (75%) were having extramarital sexual activity, in most cases with a younger partner in an unfamiliar setting and/or after excessive food and alcohol consumption The increase in absolute risk of sudden death associated with 1 hour of additional sexual activity per week is estimated to be 1 per 10 000 person-yearsLevine et al., Sexual activity and cardiovascular disease: a scientific statement from the American HeartAssociation. Circulation 2012; 125 (8): 1058-72.
  37. 37. Management of ED inCardiovascular Patients
  38. 38. Cardiovascular Risk Assessment in ED Patients Princeton Consensus Panel II Low Risk Intermediate High Risk RiskAsymptomatic; < 3 coronary ≥ 3 major coronary arteryartery disease risk factors, Unstable or refractory angina disease risk factors,excluding gender excluding gender Uncontrolled hypertensionControlled hypertension Moderate, stable angina Left ventricular dysfunction/Mild, stable angina congestive heart failure Recent myocardial infarction (NYHA class III or IV)Has had successful coronary (> 2 < 6 weeks)revascularization Recent myocardial infarction Left ventricular dysfunction/ (< 2 weeks), strokeUncomplicated past congestive heart failuremyocardial infarction (> 6–8 (NYHA class II) High-risk arrhythmiasweeks) Non-cardiac sequelae of Hypertrophic obstructive andMild valvular disease atherosclerosissuch as other cardiomyopathiesLeft ventricular dysfunction/ stroke or peripheral vascular disease Moderate or severe valvularcongestive heart failure disease(NYHA class I*)
  39. 39. Low risk Asymptomatic and <3 major risk factors Controlled hypertension Mild, stable angina pectoris Post-revascularization and without residual ischemia Post-myocardial infarction (MI) (>8 weeks), asymptomatic. Mild valvular disease Congestive heart failure (NYHA class I)The Second Princeton Consensus on Sexual Dysfunction and Cardiac Risk: New Guidelines for Sexual MedicineGraham Jackson, Raymond C. Rosen, Robert A. Kloner, John B. Kostis, Journal of Sexual Medicine, Volume 3 Page 28 - January 2006
  40. 40. Intermediate or Indeterminate Risk Asymptomatic and ≥3 CAD risk factors (excludinggender) Moderate, stable angina MI >2 weeks but <6 weeks Congestive heart failure (NYHA class II) Non-cardiac atherosclerotic sequelae (peripheral arterialdisease, history of stroke, or transient ischemic attacks)
  41. 41. High RiskUnstable or refractory anginaUncontrolled hypertensionCongestive heart failure (NYHA class III, IV)Recent MI (<2 weeks)High-risk arrhythmiasModerate to severe valve disease
  42. 42. Cardiovascular risk in ED patients Princeton Consensus Panel II SexualInquiry
  43. 43. Cardiovascular risk in ED patients Princeton Consensus Panel II Sexual ClinicalInquiry Evaluation
  44. 44. Cardiovascular risk in ED patients Princeton Consensus Panel II Sexual ClinicalInquiry Evaluation
  45. 45. Cardiovascular risk in ED patients Princeton Consensus Panel II Sexual ClinicalInquiry Evaluation Initiate or resume sexual activity Low or treatment for sexual Risk dysfunction
  46. 46. Cardiovascular risk in ED patients Princeton Consensus Panel II Sexual activity deferred until High stabilization of Risk cardiac condition Sexual ClinicalInquiry Evaluation Initiate or resume sexual activity Low or treatment for sexual Risk dysfunction
  47. 47. Cardiovascular risk in ED patients Princeton Consensus Panel II Sexual activity deferred until High stabilization of Risk cardiac condition Clinical Cardiovascular Sexual Indeterminate Evaluation assessment andInquiry Risk re-stratification Initiate or resume sexual activity Low or treatment for sexual Risk dysfunction
  48. 48. Cardiovascular risk in ED patients Princeton Consensus Panel II Sexual activity deferred until High stabilization of Risk cardiac condition Clinical Cardiovascular Sexual Indeterminate Evaluation assessment andInquiry Risk re-stratification Initiate or resume sexual activity Low or treatment for sexual Risk dysfunction
  49. 49. Sexual Activity and CVD: General Recommendations Men and women with stable CAD who have no or minimal symptoms during routine activities can engage in sexual activity. This includes patients able to achieve 3 to 5 METS during exercise stress testing without angina, ischemic ECG changes, hypotension, cyanosis, arrhythmia, or excessive dyspnea. In patients with unstable or decompensated heart disease (i.e., unstable angina, decompensated heart failure, uncontrolled arrhythmia, or severe valvular disease), sexual activity should be deferred until the patient is stabilized.Levine et al., Sexual activity and cardiovascular disease: a scientific statement from the American HeartAssociation. Circulation 2012; 125 (8): 1058-72.
  50. 50. According to the American College of Cardiology guidelines, Resumption ofsexual activity after uncomplicated MI is allowed after 1) 1-2 weeks 2) 3-4 weeks 3) 6-8 weeks
  51. 51. Sexual Activity after Myocardial InfarctionBefore the routine use of reperfusion therapy (thrombolytic therapy or percutaneouscoronary intervention) it was recommended that sexual activity be avoided for 6 to8 weeks after MI.In 2005, the Princeton Conference suggested that post -MI patients who hadundergone successful coronary revascularization or had a treadmill test withoutischemia could resume sexual activity 3 to 4 weeks after MI.The American College of Cardiology guidelines for the management of patients withST-elevation Myocardial Infarction allowed sexual activity as early as 1 week afterMI in the stable patient.Because participation of stable patients in cardiac rehabilitation 1 week after MI hasproved safe, resumption of sexual activity soon after uncomplicated MI seemsreasonable in the stable patients who are asymptomatic with mild to moderatephysical activity (eg, 3–5 METS).Antman et al, . ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of theAmerican College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation 2010;121:e441
  52. 52. Sexual Activity after Myocardial Infarction Exercise training during cardiac rehabilitation increases maximum exercise capacity and decrease peak coital heart rate. Regular exercise is associated with a decreased risk of sexual activity–triggered myocardial infarction. Thus, cardiac rehabilitation and regular exercise are reasonable strategies in patients with stable CAD who plan to engage in sexual activity.Muller JE, Mittleman MA, Maclure M, Sherwood JB, Tofler GH; Determinants of Myocardial Infarction Onset StudyInvestigators. Triggering myocardial infarction by sexual activity: low absolute risk and prevention by regularphysical exertion. JAMA. 1996; 275: 1405– 1409Stein RA. The effect of exercise training on heart rate during coitus in the post myocardial infarction patient.Circulation. 1977; 55: 738– 740.
  53. 53. Sexual Activity after Percutaneous Coronary Intervention (PCI) The cardiovascular risk of sexual activity after PCI is related to the adequacy of coronary revascularization. Patients with complete revascularization should be able to resume sexual activity within days of PCI, provided there are no complications related to femoral vascular access. Patients who undergo PCI via radial access should be able to resume sexual activity as early as if not earlier than those who undergo PCI via the femoral access. In patients with incomplete coronary revascularization, exercise stress testing may be of benefit in assessing the extent and severity of residual ischemia.Levine et al., Sexual activity and cardiovascular disease: a scientific statement from the American HeartAssociation. Circulation 2012; 125 (8): 1058-72.
  54. 54. Sexual Activity after Coronary Artery Bypass Graft Surgery Sexual activity may involve considerable stress on the chest and breathing patterns, that generate high intrathoracic pressures, that could compromise sternal wound healing It is recommended that sexual activity be delayed for 6 to 8 weeks after bypass surgery. Patients should avoid positions that put stress on the surgical site, and physical vigor is best reintroduced in a gradual fashion. Robot-assisted surgery avoids sternum incision; patients treated with this procedure may be able to resume sexual activity earlier than those undergoing open surgeryLevine et al., Sexual activity and cardiovascular disease: a scientific statement from the American HeartAssociation. Circulation 2012; 125 (8): 1058-72.
  55. 55. Cardiovascular Drugs and Sexual Function
  56. 56. Numerous classes of cardiovasculardrugs, particularly β-blockers, are thecause of ED in Many Coronary artery disease patients1) True2) False
  57. 57. Cardiovascular Drugs and ED Numerous classes of cardiovascular drugs, particularly diuretics and β-blockers, have been implicated in causing ED; however, recent studies have not found clear relationships between many contemporary cardiovascular drugs and ED. An analysis of 6 studies of 15 000 patients found β-blocker increased the annual rate of sexual dysfunction by only 5 reports per 1000 patients and the annual rate of ED by only 3 per 1000 patients. A nocebo effect, in which a patients knowledge that a drug has been associated with ED, is an important contributing factor to ED Cardiovascular drugs that improve symptoms and survival should not be withheld because of concerns about the potential impact on sexual functionKo DT, Hebert PR, Coffey CS, Sedrakyan A, Curtis JP, Krumholz HM. Beta-blocker therapy and symptoms ofdepression, fatigue, and sexual dysfunction.JAMA. 2002; 288: 351– 357
  58. 58. Efficacy of PDE5 Inhibitorsfor Men with Ischemic Heart Disease
  59. 59. Effects of PDE5 Inhibitors on Erection in Men with Ischemic Heart DiseaseResponse to Q3 and Q4 of the IIEFMeta analysis of 9 double-blind placebo-controlled studies*P < 0.0001 vs placebo Conti CR, et al. Am J Cardiol. 1999;83(5A):29C-34C
  60. 60. Effects of PDE5 Inhibitors on Erection in Men with Ischemic Heart DiseaseIIEF-EF score (combined response to Q1-Q5, 15 of the IIEF score)Meta analysis of 9 double-blind placebo-controlled studies*P < 0.0001 vs placebo Conti CR, et al. Am J Cardiol. 1999;83(5A):29C-34C
  61. 61. Effects of PDE5 Inhibitors on Erection in Men with Ischemic Heart Disease Four domains of International Index of Erectile Function Meta analysis of 9 double-blind placebo-controlled studies*P < 0.05 vs placebo Conti CR, et al. Am J Cardiol. 1999;83(5A):29C-34C
  62. 62. Safety of PDE5 Inhibitors for Men with Ischemic Heart Disease
  63. 63. PDE5 Inhibitors for Cardiac Patients PDE5 inhibitors are generally safe and effective for the treatment of ED in patients with arterial hypertension, stable CAD, and compensated heart failure. No studies have shown one agent to be more effective or safer than the others. Despite occasional anecdotal case reports linking PDE5 inhibitors to cardiac events, large trials and meta-analyses suggest that they are not associated with an increase in MI or cardiac events.Kloner RA. Cardiovascular effects of the 3 phosphodiesterase-5 inhibitors approved for the treatment of erectiledysfunction. Circulation. 2004; 110: 3149–3155Kloner et al., Cardiovascular safety update of tadalafil: retrospective analysis of data from placebo-controlled andopen-label clinical trials of tadalafil with as needed, three times-per-week or once-a-day dosing. Am J Cardiol.2006;97: 1778– 1784
  64. 64. PDE5 Inhibitors for Cardiac Patients The concomitant use of PDE5 inhibitors and α-blocking agents may result in symptomatic hypotension.Thus, when both are indicated, the lowest α-blocker dose should be initiated and tolerated by the patient before the patient begins the lowest dose of a PDE5 inhibitor. PDE5 inhibitors should not be administered to treat ED in patients who are already receiving PDE5 inhibitor therapy for pulmonary hypertension. Vardenafil (but not sildenafil or tadalafil) carries a precautionary statement about prolongation of QT interval and should be avoided in patients with congenital QT prolongation and in those taking medications known to prolong the QT interval.Levine et al. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association.Circulation 2012; 125 (8): 1058-72.
  65. 65. PDE5 Inhibitors for Cardiac Patients Organic nitrates remain an absolute contraindication to PDE5 inhibitor use, because this combination may result in unpredictable reductions in systemic blood pressure. Patients with chest pain or acute MI should not be administered nitrates until at least 24 hours after the last dose of sildenafil or vardenafil and until 48 hours after the last dose of tadalafil. In patients on chronic nitrate therapy who desire to use PDE5 inhibitors, the need for continued nitrate therapy should be evaluated, particularly in patients who have undergone complete revascularization.Cheitlin et al; Technology and Practice Executive Committee. Use of sildenafil (Viagra) in patients with cardiovasculardisease. Circulation. 1999; 99: 168– 177Kloner et al. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol. 2003;42: 1855– 1860
  66. 66. Herbal Medications Numerous herbal medications are advertised to patients to treat ED. Some of these medications may contain drugs, such as PDE5 inhibitors, yohimbine, or L-arginine. Such drugs may interact with cardiovascular medications, have vasoactive or sympathomimetic properties, can elevate or reduce systemic blood pressure, or have been associated with adverse outcome in patients with CAD. It may be reasonable to caution patients with CVD about the use of herbal medications with unknown ingredients.Savaliya et al. Screening of Indian aphrodisiac ayurvedic/herbal healthcare products for adulteration with sildenafil,tadalafil and/or vardenafil using LC/PDA and extracted ion LC-MS/TOF. J Pharm Biomed Anal. 2010; 52: 406– 409Kearney et. Adverse drug events associated with yohimbine-containing products: a retrospective review of theCalifornia Poison Control System reported cases. Ann Pharmacother. 2010; 44: 1022– 1029
  67. 67. Patient and Partner Counseling afterMyocardial In farction
  68. 68. Sexual Counseling Following Acute Myocardial Infarction Although sexual counseling of patients and partners with CVD is an important component of recovery, it is rarely provided. Potential reasons include the lack of experience or comfort discussing sexual issues, inadequate knowledge regarding sexual activity and CVD, and limited time Partners of patients with CVD often have considerable anxiety about sexual activity, which may adversely impact the sexual activity of the couple When information is provided, it is more likely provided in written form than verbally, more likely to be provided to men than to women, and rarely provided to the partnerIvarsson B, Fridlund B, Sjöberg T. Information from health care professionals about sexual function and coexistenceafter myocardial infarction: a Swedish national study. Heart Lung. 2009; 38: 330– 335.
  69. 69. Sexual Counseling Following Acute Myocardial Infarction 164 post MI patients 100 80 60 39.6% 40 21.9% 20 14.6% 10.4% 11.5% 6.3% 0 resume sexual activity When to use of NTG for being well Warning signs to report rested before activity Eating and drinking before activity pain during activity Effects of medications on sexual activitySteinke E, Patterson-Midgley P. Sexual counseling following acute myocardial infarction. Clin Nurs Res 1996;5 (4): 462-72.
  70. 70. Sexual Counseling Following Acute Myocardial Infarction A discussion about sexual activity is appropriate for men and women of all ages after MI. General suggestions to the patient may include being well rested at the time of sexual activity, avoiding unfamiliar surroundings and partners to minimize stress during sexual activity, avoiding heavy meals or alcohol before sexual activity, and using a position that does not restrict respiration. The achievement of orgasm may require a greater degree of exertion and may not be a realistic initial goal in some patients after MI. Randomized trials have demonstrated that sexual counseling increased the likelihood of return to sexual activity, improved sexual desire and satisfaction, and increased confidence and reduced fear of resuming sexual activityFroelicher ES, Kee LL, Newton KM, Lindskog B, Livingston M. Return to work, sexual activity, and other activities afteracute myocardial infarction. Heart Lung. 1994; 23: 423– 435
  71. 71. Take Home Messages
  72. 72. Take Home MessageCountries in the Middle East bear a heavy burden fromcardiovascular disease.Patients in the Middle East present with myocardialinfarction at a younger age, compared with patientselsewhere.The projected future burden of mortality from coronary heartdisease in the Middle East is set to outstrip that observed inother geographical regions
  73. 73. Take Home MessageIt is reasonable that patients with CVD wishing to initiateor resume sexual activity after MI be evaluated with athorough medical history and physical examinationExercise stress testing is reasonable for patients who arenot at low cardiovascular risk or have unknowncardiovascular risk to assess exercise capacity Sexual activity is reasonable for patients who can exercise≥3 to 5 METS without angina, excessive dyspnea,ischemic ST-segment changes, cyanosis, hypotension, orarrhythmia
  74. 74. Take Home MessageCardiac rehabilitation and regular exercise can be useful toreduce the risk of cardiovascular complications with sexualactivity after MISexual activity is reasonable 1 or more weeks afteruncomplicated MI if the patient is without cardiac symptomsduring mild to moderate physical activitySexual activity is reasonable for patients who have undergonecomplete coronary revascularization and may be resumed (a)several days after percutaneous coronary intervention if thevascular access site is without complications or (b) 6 to 8weeks after standard coronary artery bypass graft surgery,provided the sternotomy is well healed
  75. 75. Take Home MessageCardiovascular drugs that can improve symptoms andsurvival should not be withheld because of concernsabout the potential impact on sexual functionPDE5 inhibitors are effective and safe for the treatment of EDin patients with stable CADIt may be reasonable to caution patients with CVD regardingthe potential for adverse events with the use of herbalmedications with unknown ingredients that are taken fortreatment of sexual dysfunction
  76. 76. Take Home MessageAnxiety and depression regarding sexual activity shouldbe assessed in patients with CVDPatient and spouse/partner counseling by healthcareproviders is useful to assist in resumption of sexualactivity after an acute cardiac event or new CVDdiagnosisA public awareness education program is needed toencourage men with ED to seek medical advice early,where risk factors of CAD are assessed
  77. 77. Sexual Activity AfterMyocardial Infarction Tarek Anis, M.D. Prof. of Andrology, Cairo University

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