Jeff Unger, MD, ABFM, FACE

SYNOPSIS: Although the U.S. and European cardiovascular society guidelines recommend that patients be counseled about resuming sexual activity after suffering an acute myocardial infarction (AMI), the actual demographics of sexual education post-myocardial infarction (MI) are unknown. The prospective, longitudinal Variation in Recover: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study evaluated the gender differences in baseline and sexual activity, function, and patient experience with physician counseling following acute MI. Among the 2349 women and 1152 men interviewed, only 12% of women and 19% of men reported discussing sexual activity with a physician within a month following AMI. Women received more restrictions than men, few of which were supported by evidence or guidelines.

SOURCE: Lindau ST, et al. Sexual activity and counseling in the first month after acute myocardial infarction (AMI) among younger adults in the United States and Spain: A prospective, observational study. Circulation 2014. Dec 15. DOI: 10:161/circulationAHA.114.012709.

Acute myocardial infarction (AMI) can result in reduced sexual activity and function, as patients may fear that sexual intercourse may trigger another fatal event. Loss of sexual activity following AMI can increase one’s risk of major depression, resulting in strained relationships and diminished quality of life. Childbearing potential may be affected in younger patients. Lack of understanding of sexuality post-MI can compromise adherence to medical care and is associated with poorer overall outcomes.

 

Table 1. Sexual Activity And Cardiovascular Disease (CVD) : General Recommendations

1. Women with CVD should be counseled regarding the safety and advisability of contraceptive methods and pregnancy when appropriate.

2. It is reasonable that patients with CVD wishing to initiate or resume sexual activity be evaluated with a thorough medical history and physical examination.

3. Sexual activity is reasonable for patients with CVD who, on clinical evaluation, are determined to be at low risk of cardiovascular complications.

4. Exercise stress testing is reasonable for patients who are not at low cardiovascular risk to assess
exercise capacity and development of symptoms, ischemia, or arrhythmias.

5. Sexual activity is reasonable for patients who can exercise > 3-5 METS without angina, excessive dyspnea, ischemic ST-segment changes, cyanosis, hypotension, or arrhythmia.

6. Cardiac rehabilitation and regular exercise can be useful to reduce the risk of cardiovascular complications with sexual activity for patients with CVD.

7. Patients with unstable, decompensated, and/or severe symptomatic CVD should defer sexual activity until their condition is stabilized and optimally managed.

8. Patients with CVD who experience cardiovascular symptoms precipitated by sexual activity should
defer sexual intercourse until their condition is
stabilized and optimally managed.

Reference: Levine GN, et al. Sexual activity and cardiovascular disease. A scientific statement from the American Heart Association. Circulation 2012;125:1058-1072.

 

The risk of coital death is rare, with only 0.6% of sudden deaths attributable to sexual intercourse. Less than 1% of all MIs occur during sexual activity. Although sexual activity can trigger MI, the relative risk is low, with a slight increase in risk within 2 hours of sexual activity. Even in high-risk individuals with previous MI, the annual risk is 1.10% vs 1.0% in the population at large. This risk appears to apply equally to men and women.

Sexual intercourse can be related to performing moderate physical activity, similar to walking, lifting, and light housework. Heart rates rarely exceed 130 beats/min, and systolic blood pressures are generally less than 170 mmHg. However, there is some individual variation, based on age and general physical conditioning, with some patients attaining heart rates up to 180 beats/min with orgasm. Patients with known coronary artery disease may develop malignant arrhythmias during intercourse.

COMMENTARY

Clinicians should take the time to stratify their post-MI patients as being low or high risk. Patients who have stable angina, no evidence of congestive heart failure, stable blood pressure, and are adherent to their prescribed drug regimen may begin sexual activity 1 week following their acute event. The American Heart Association published guidelines for resumption of sexual activity following AMI are noted in Table 1. High-risk patients should undergo stress testing prior to approving their return to sexual activity. Patients with symptomatic valvular heart disease should delay sexual activity until their medical condition is stabilized and optimally managed. 

REFERENCES

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  4. Levine GN, et al. Sexual activity and cardiovascular disease. A scientific statement from the American Heart Association. Circulation 2012;125:1058-1072.
  5. Moss AJ, Benhorin J. Prognosis and management after a first myocardial infarction. N Engl J Med 1990;322:743-753.