Pillow Talk: First AHA Advice on Sex and CVD

January 19, 2012

January 19, 2012 (Houston, Texas) — New advice indicates that sexual activity is safe for the majority of heart disease patients and that doctors--as well as patients and their partners--should endeavor to bring up the subject of sex in discussions [1]. The guidance comes from the first-ever American Heart Association (AHA) scientific statement to address the issue, which is published online today in Circulation.

Lead author Dr Glenn N Levine (Baylor College of Medicine, Houston, TX) told heartwire that the recommendations are probably the most comprehensive on the subject to date and have been compiled by experts from various fields, including cardiology, exercise physiology, sexual counseling, and urology. Physicians, patients, and partners are reluctant to talk about sexual activity, but it is something "that is important to quality of life for most people, and we would not want to see patients refraining from sex out of undue concern about precipitating a heart attack or sudden death," he observes.

We would not want to see patients refraining from sex out of undue concern about precipitating a heart attack or sudden death.

The only patients who should refrain from sex are those with unstable heart disease or severe symptoms; they should be assessed and stabilized with appropriate treatment before engaging in sexual activity, says Levine. And drugs that can improve cardiovascular symptoms or survival should not be withheld due to concerns that they may have an impact on sexual function, he notes.

He also stresses that while use of phosphodiesterase-5 (PDE-5) inhibitor erectile-dysfunction drugs, such as sildenafil (Viagra, Pfizer) are generally safe for men who have stable cardiovascular disease, these agents are absolutely contraindicated in patients receiving nitrate therapy, either long-acting preparations or sublingual ones.

Fear, Anxiety, and Depression Can Underlie Avoidance of Sex

The AHA guidance gives general recommendations for sexual activity and CVD but also advice pertaining to patients with specific conditions: coronary artery disease; heart failure; valvular heart disease; those with arrhythmias and/or pacemakers or implantable cardioverter defibrillators (ICDs); congenital heart disease; and hypertrophic cardiomyopathy. And it covers cardiovascular drugs and sexual function as well as pharmacotherapy for sexual dysfunction.

One of the main purposes of the statement "is to make physicians and healthcare providers aware that this is a real issue that is not appropriately addressed with the patient and partner and truly should be," says Levine.

"At the same time--because we are getting a lot of lay press attention to this issue--we hope to make patients and their partners aware that sexual activity is something they should feel free to discuss with their healthcare providers during an office visit or before hospital discharge.

We hope to make patients and their partners aware that sexual activity is something they should feel free to discuss with their healthcare providers.

"The important thing to emphasize is that the risk of heart attack with sexual activity is only extremely modestly increased during sexual activity and represents only a miniscule amount of a person's overall risk."

Levine also wants to highlight the fact that anxiety and depression should be important considerations in patients with cardiovascular disease and can contribute to reduced or impaired sexual activity. "Sexual counseling of CVD patients and their partners is an important component of recovery; unfortunately, it is rarely provided," he and his coauthors observe.

Advice Should Help All Doctors to Advise CVD Patients on Sex

The scientific statement has been published in a cardiology journal, Levine notes, because "the cardiologist is going to be asked to comment on this, and frequently the GP will often refer the patient to the cardiologist to address issues" relating to sexual activity, he notes. For example, one subject he is frequently consulted about by other doctors is whether patients can use erectile-dysfunction drugs.

Levine hopes, however, that the new recommendations will embolden other specialists to confidently advise patients: "One of the aims is to allow GPs, family doctors, and others to, at least for the majority of patients, give reasonable guidance."

Another important consideration raised in the AHA statement--which is also endorsed by the American Urological Association, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association of Cardiovascular and Pulmonary Rehabilitation, International Society of Sexual Medicine, American College of Cardiology Foundation, Heart Rhythm Society, and Heart Failure Society of America--is that cardiac rehabilitation and regular physical activity can reduce the risk of cardiovascular complications in people with heart disease.

Exercise testing can also provide additional information as to the safety of sexual activity in patients with indeterminate or unclear risk, the authors note.

They conclude that further research is needed on sexual activity in specific cardiovascular conditions, particularly with regard to the effects in females and in older adults.

Levine has reported that he has no conflicts of interest. Disclosures for the coauthors are listed in the paper.