Effect of Cardiac Rehab on Sexual Health Unclear, Poorly Studied

Patrice Wendling

December 07, 2018

Individuals stricken with heart disease can expect to improve numerous outcomes by attending cardiac rehabilitation, but how these programs will affect their sexual health remains an open question.

A systematic review of 14 studies reported conflicting results for sexual activity (SA) outcomes and cardiac rehabilitation across a range of different programs of different durations, intensities, and patient populations. Although physical fitness appeared to be a particularly important aspect of rehabilitation for improving sexual health, formal sexual counseling did not.

"Every program consisted of an exercise component, which seems to be associated with generally equivocal or positive sexual outcomes likely through improvement of aerobic capacity, so certainly we would recommend that," said senior author Karen L. Tang, MD, MSc, University of Calgary, Alberta, Canada.

"The difficulty is that the nonexercise components, such as psychologic counseling and education, around risk factor reduction were varied across studies and not all programs included all components," she added. "So how best to meet patients' sexual needs in cardiac rehabilitation remains unknown."

Sexual problems are common in patients with cardiovascular disease (CVD) because of physical limitations and/or psychosocial problems, such as anxiety and depression. Use of antihypertensive drugs is associated with decreased sexual response in women and sexual dysfunction in men. Overall, 46% of men with coronary artery disease and 84% of those with heart failure suffer from erectile dysfunction, note the authors.

The study, published in the Canadian Journal of Cardiology December 6, however, brings into sharp relief the surprising lack of evidence on such a fundamental issue for patients with heart disease (HD) and their partners.

"Could we expect that patients with HD attending cardiac rehabilitation (CR) programs will improve their sexual activity? Although initially most of us would consider it likely to be true, this very relevant topic has been scarcely investigated and discussed in the literature," Claudio Gil Soares de Araújo, MD, PhD, and colleagues write in an accompanying editorial.

"Methodological challenges also exist regarding research on sexual activity," note the editorialists. "The first struggle is to operationally define it."

Indeed, the investigators' efforts to perform a meta-analysis were stymied because of the wide variety of methods and outcomes used in the three prospective cohort studies, six randomized, and five nonrandomized trials that comprised the analysis.

Although all the studies reported on at least one SA outcome, only five used SA-specific measures, such as the Sex After ICD Survey, Arizona Sexual Experience Scale, or International Index of Erectile Function-5. One study used semi-structured interviews, three included a SA outcome within a broader questionnaire, and six used author-created questionnaires. Reported SA outcomes of interest were sexual function/dysfunction, satisfaction, resumption, and frequency.

Eleven studies tested outpatient-based CR and three tested both inpatient and outpatient CR. Follow-up duration was 3 weeks to 60 months.

At least three-quarters of patients were male (mean ages, 52.7 to 87.3 years). CVD diagnoses were first-time cardioverter defibrillator implantation, ischemic heart disease, MI, unstable angina or non-ST-segment MI, coronary artery bypass grafting, and percutaneous coronary intervention.

Of the six studies that reported on sexual function/dysfunction — the most significant and commonly studied outcome — three showed a statistically significant benefit to cardiac rehabilitation and two reported a neutral effect.

One study conducted only in men reported a significant harm, with patients having more erectile dysfunction and a lack of orgasm during a 3-month outpatient program with prescribed and supervised exercise (18% to 23%; P < .0001).

"This was the only study that reported worse outcomes with cardiac rehab attendance," Tang said. "We don't know how to explain it because there wasn't anything that stood out from either the population or the intervention characteristics that were drastically different compared to the other studies."

Of the nine studies with a psychological component, only four included a SA-specific component, such as counseling on the sexual aspects of recovery or education on body image, sexuality, and avoidance behavior. All four of these studies reported nonsignificant findings for each SA outcome tested.

This is consistent with a recent Cochrane systematic review of three trials that found no high-quality evidence to support the effectiveness of sexual counseling for patients with CVD.

"More generic sexual counseling may not get at the very specific anxieties that CVD patients may have around sexual activity and function, such as sexual activity triggering another event or concerns around medication side effects," said Tang.

Soares de Araújo and colleagues say that "it seems unlikely that standardized sexual counseling protocols in the context of CR could effectively treat sexual dysfunction secondary to HD."

They also note that a 2016 multisociety consensus document showed that "sexual problems are rarely addressed during CR because of time and resource limitations, as well as staff-related barriers such as lack of specific professional training, low knowledge and confidence, and personal discomfort with sexual issues."

The pilot Cardiac Health and Relationship Management and Sexuality (CHARMS) study, however, recently reported successful implementation of an in-hospital cardiac rehabilitation intervention, consisting of awareness training and skills development for staff and education and support for patients.

Going forward, Tang and colleagues recommend use of the National Institute of Health's Obesity-Related Behavioral Intervention Trials (ORBIT) framework to develop and test new behavioral interventions related to SA. Although future studies might identify specific CR program components that can address the unique needs of patients with CVD, the elephant in the room is that cardiac rehabilitation itself is grossly underutilized.

"A referral to cardiac rehab doesn't mean that people will attend," Tang said. "If patients see cardiac rehab as more than just a program to improve exercise capacity — that it is an opportunity to focus on changes to their function and to improve quality of life — they may be more inclined to attend."

The authors report no conflicts of interest. Soares de Araújo and his fellow editorialist Aline Sardinha, PhD, report no conflicts of interest. Ricardo Stein, MD, ScD, the other editorialist, is recipient of a research scholarship from CNPq–Brasilia, the Brazilian National Council for Scientific and Technological Development.

Can J Cardiol. 2018;34:1590-1598 and 1546-1548. Abstract, Editorial

Follow Patrice Wendling on Twitter: @pwendl. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.

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