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Sexual activity after heart problems

by Janet Casperson, BS, MSN, ANP-C

Sexual activity can be an extremely healthy and enjoyable form of exercise that two people can do together. However, in many circumstances precautions must be taken to practice safe sex. While this article is not about sexually transmitted diseases (STDs), a reminder is in order: if you are having sex with an unknown partner, take proper precautions.

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This article is about cardiovascular risk factors and sexual activity. We want to identify people who can have sex safely, without known risk of a cardiovascular event. To summarize the entire article: if you are currently having a heart attack, you cannot have sex safely!

Can Sex Cause a Heart Attack?

The story of Karen and Robert, a delightful, fun-loving couple whom we have the privilege to treat for ED, is one that we will always remember:

Robert was an uncontrolled diabetic with hypertension and high cholesterol levels. After extensive efforts on Robert and Karen's part, his condition is now well controlled. The ED disorder which had been treated successfully for several months with penile injections became progressively worse. The penile injections eventually failed and Robert and Karen decided that the next treatment would be for Robert to undergo a surgery called an insertion of penile prosthesis, commonly called a penile implant. The surgery was successful and the couple demonstrated proficiency at manipulation of the device and was cleared to use the penile implant and frequently.

On the first follow up visit Karen shared their story:

Robert was chasing me around the house, like he did when we were 20 years old and newly wed. I let him catch me right at his recliner. Well, things got carried away, my night gown was up to my hips, the implant was inflated and Robert and I had a lot of fun. However, I have arthritis and high blood pressure and I just don't move the same as I did when we were 20. My left foot got caught in the chair between the arm and the seat and we could not get it out. It took the fire department to release me from the chair. I became short of breath and felt my heart beating fast; I think I almost had a heart attack. What if I had a heart attack? What if my neighbors found out? What would they think?

Robert just smiled as Karen told their story. Karen was given reassurance that, indeed, she and Robert had cardiovascular systems that were strong enough so that she didn't have to worry about either one of them having a heart attack from sexual activity. They were sent home with specific instructions to ensure that Karen's foot didn't get stuck in the chair and the assurance that their story would never be forgotten, or repeated (names were changed here to protect the innocent).

Cardiovascular Risk and Sexual Activity

The question of resuming sexual activity and heart health is on the mind of many couples when one partner has cardiovascular risk factors. However, the research on death during sexual activity indicates that this level of activity is not dangerous to the heart. Sex in a familiar relationship is not stressful on the heart. The response is similar to mild to moderate intensity exercise for the middle aged male. However, sex with an unfamiliar partner may increase the workload of the heart, especially if other factors, such as eating large meals and alcohol consumption, known to increase the work load of the heart are involved.

To date there have been three large significant studies conducted in Berlin, Frankfurt and Japan. Sudden post coital death as the primary cause of death had an incidence of was less than two percent; men were the victim over 82% of the time and extramarital sex accounted for over 75% of the deaths. The general rule that we follow in clinical practice is, "if you can walk up a flight of stairs without experiencing chest pain or severe shortness of breath, you can participate in sexual activity with your familiar partner in a familiar surrounding without further cardiac workup. If it is not a familiar surrounding and/or familiar partner, you better be able to go two flights or more."

The Princeton Consensus Conference in 1999 gave health care providers clear and concise guidelines for the treatment of sexual dysfunction and the risk with cardiovascular disease. The expert panel reconvened in June 2004 and further developed, expanded and clarified the guidelines for evaluating the degree of cardiovascular risk associated with sexual activity for men with varying degrees of cardiovascular disease. These guidelines were published in 2005. (Kostis JB, Jackson G, Rosen R, Barrett-Connor E, et al. Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference. Am J Cardiol. 2005 Dec 26; 96(12B):85M-93M. Epub 2005 Dec 27.)

The Panel divided individuals with cardiovascular risk factors into three groups with subgroups and clarified their risk for a cardiac event related to sexual activity. The groupings are low-risk patients, intermediate or indeterminate-risk patients and high-risk patients.

People with major cardiovascular risk factors such as age, male gender, hypertension, diabetes mellitus, cigarette smoking, dyslipidemia, sedentary lifestyle and a family history of premature coronary artery disease were identified. Other risk factors included obesity, metabolic syndrome, elevated inflammatory markers, ethnicity, stress and recreational drug use. These risk factors were discussed in detail in another article.

Low risk cardiovascular patients can safely have sex

This group includes:

  • less than three (excluding male gender) of the above major risk factors or cardiovasculardisease and are asymptomatic (without any symptoms)
  • controlled hypertension, or high blood pressure, that is controlled with one or more medications
  • well-controlled, mild, stable angina (chest pain)
  • Patients who have:
    -- experienced a myocardial infarction (MI) more than 6-8 weeks past,
    -- revascularization of the coronary arteries,
    -- mitral valve disease,
    -- left ventricular heart dysfunction or heart failure class I and;
    -- other cardiovascular conditions such as controlled atrial fibrillation.

Intermediate or indeterminate risk patients should be evaluated before having sex

Intermediate or indeterminate risk patients were defined as people who had an uncertain cardiovascular condition. This group of people was advised to have further cardiac evaluation prior to resuming sexual activity.

Their conditions include:

  • asymptomatic with more than three (excluding male gender) major risk factors,
  • moderate stable angina,
  • past MI less than 6 weeks ago and more than two weeks ago,
  • left ventricular heart dysfunction class II,
  • evident peripheral artery disease, stroke and transient ischemic attacks.

The high risk group should not have sex until cardiac condition is stabilized

The high risk group of cardiac patients consists of people who are at significant risk for a cardiovascular event related to sexual activity. This group is unstable and should not participate in sexual activity until their cardiac condition is stabilized. Diagnoses for this group include:

  • unstable angina,
  • uncontrolled hypertension,
  • MI of less than two weeks ago,
  • left ventricular dysfunction class III or IV, and
  • severe valvular disease (particularly aortic stenosis).

Hypertension and Sexual Activity

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Well-controlled hypertension, or high blood pressure, is not a contraindication for sexual activity. In fact, sexual activity is useful in controlling hypertension. However, uncontrolled hypertension is different and will place a person at risk for a cardiac event with sexual activity. Some of the medications used to treat hypertension have the potential side effect of ED but this cause of ED is easily treated. The most common medications to treat hypertension that may cause ED are beta blockers and thiazide diuretics. Angiotension II receptor antagonists and doxazosin are the least likely to cause ED. Caution should be used when combining medications such as alpha blockers with PDE-5 inhibitors because the combination may cause a further decrease in blood pressure, light headedness, or even dizziness. We recommend that the two types of drugs should be taken at least four hours apart.

Angina and Sexual Activity

Angina, no matter the classification of the disorder, requires the heart to work harder. Even people with mild, stable angina requiring medical therapy should undergo further noninvasive evaluation prior to participating in sexual activity. Moderate stable angina increases the work of the heart even more and the risk of myocardial ischemia increases with sex. Exercise testing is recommended prior to recommending sexual activity for people with moderate stable angina. Any person experiencing unstable angina should be admitted to the hospital for evaluation and treatment. They should not be sexually active until the angina is stabilized and they are cleared by a cardiologist for sexual activity.

Past Heart Attack and Sexual Activity

Past myocardial infarction (MI), or heart attack, does not exclude a person from resuming sexual activity if the person is at least six to eight weeks past the MI and not having symptoms. Because sexual activity requires work of the heart, the patient who is only 2-4 four weeks post MI should undergo stress testing prior to resuming sexual activities. Special precautions include playing a more passive role with sexual activity and avoiding any sexual activity that would grossly increase the work of the heart. Sexual activity should be resumed slowly. Foreplay or pre-intercourse love making is essential and we suggest that the patient start with gentle kisses, mutual petting, caresses and cuddling. As confidence grows, sexual activity can be progress to a more normal level. We do not recommend that the heart patient take the active role. A comfortable side-to-side position is recommended. If chest pain, shortness of breath, increased heart rate, palpitations, anxiety or other signs of distress occur, slow down.

Sexual Activity After Heart Surgery

Cardiac revascularization is accomplished by different methods. The methods that the Panel addressed were coronary artery bypass graft (CABG) and percutaneous coronary interventions such as stenting and angioplasty. Original recommendations indicated that the risk was directly related to the level of successful revascularization; the Panel's later recommendations included evaluation by exercise stress testing. The sternal scar from surgery may be a source of pain, so we advise a side-to-side position or patient on top to minimize the discomfort. Another tip is that the male chest hairs that grow back bristly after surgery may be uncomfortable for the partner. Positions in which the chest does not contact the partner's skin or using fabric or a pillow between partners may be more comfortable.

Congestive Heart Failure and Sexual Activity

Left ventricular dysfunction, congestive heart failure, commonly called heart failure does not represent a contraindication for sexual activity if it is class I. Precautions must be taken if the disorder progresses into class II, III and IV because people are more at risk for developing an irregular heart beat that could cause death. An implantable defibrillator or pacemaker decreases the risk for these life threatening heart beats. With the more advanced classes, heart failure symptoms may be the limiting factor for sexual activity. The partner with the heart failure certainly should be the more passive partner, frequently relying on the other partner to do the major work associated with sex.

Heart Valve Disease and Sexual Activity

Mild mitral valvular disease is not a disorder that would prevent sexual activity and prior treatment with antibiotics is not needed. However, if the patient has significant aortic stenosis, the risk of sudden death is higher and can be increased by the effects of vasodilators such as the PDE-5 inhibitors. Therefore, caution should be used when taking PDE-5 inhibitors with aortic stenosis.

Stroke and Sexual Activity

Cerebrovascular accidents or strokes occur more frequently at night or early morning. Recent studies indicate that sexual activity not only does not increase the risk for stroke, but has actually demonstrated protection from cardiovascular events. If the couple was sexually active prior to the stroke there are few reasons that would prevent the return of sex for the couple. However, for the person who has experienced a stroke, resuming sexual activities can present many challenges because strokes are usually followed by decreased libido, depression, fatigue and physical limitations. Starting off slowly with gentle kissing, touching, mutual petting, caressing and cuddling is recommended. Urinary catheters can be removed from males and reinserted after sex, or folded back over the erect penis and covered with a prelubricated condom. Female catheters may be taped to the abdomen or thigh. If total or partial paralysis is involved, the stroke victim should assume the more passive role and the couple should select reasonable positions. Stroke victim on back with the partner on top, side to side positions with added support for the stroke victim and the sitting position are all recommended. We do not recommend the use of sex swings or other sexual devices that require strength and coordination for the stroke victims.

Viagra and Heart Disease

Questions about medication safety are frequently asked by people who have cardiovascular risk factors or a family history of cardiovascular disease. The question that is on the minds of men with CVD and their partners is "how risky are the medications for the treatment of ED?" Lifestyle modifications are considered the first line of therapy. PDE-5 inhibitors like Viagra®, Levitra® and Cialis® are considered the second line of treatment, only after life style modifications. There have been no studies that show the use of these medications is linked to MI or other cardiovascular events in men. Studies indicated that there are NO changes in exercise EKG, workload of the heart, decrease in blood pressure, increase in cardiac ischemia or increased heart rate with the use of these drugs. Therefore, this classification of medications is not only safe, but may have benefits. Recent studies on Viagra® have demonstrated cardiac benefits for endothelial function, improved cardiac output and decreased blood pressure with patients who have pulmonary hypertension.

However, these medications do have an interaction with nitrates and should not be taken with other medications containing nitrates or with the recreational drug called "poppers" (amyl nitrate). Men who develop chest pain after taking PDE-5 inhibitors Viagra® and Levitra® are advised not to take nitroglycerin within 24 hours. Nitroglycerin should not be taken within 48 hours of taking Cialis®. Alpha blockers are a class of medication commonly used to treat an enlarged prostate known as benign prostatic hyperplasia or BPH. These medications also decrease blood pressure and we do not recommend taking an alpha blocker and a PDE-5 inhibitor within four hours of each other.

In summary, you would have to be very ill for the risk of sexual activity to outweigh the benefits. However, some people need to use caution and modify sexual techniques for physical safety issues. Therefore, if you are an older male, in an unfamiliar surrounding away from home and you are outside of your familiar caring relationship, you may want to exercise a little more caution than just a condom. We recommend and encourage a healthy sexual relationship for people with cardiovascular risk factors for both physical and psychological benefits.

References: See Bibliography

August 2006
Posted August 2008
Updated September 2009

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