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HEART Insight:
doi: 10.1097/01.HEARTI.0000414786.30372.9a
Features: Recovery Room

Let's talk about sex: After a heart attack

Stephens, Stephanie

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In most circles, conversations about sex aren't exactly shouted from the rooftops. Even in the doctor's office, the touchy subject often takes the form of a “doorknob diagnosis,” just as the patient heads out the door.

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“Uh, doctor, by the way, I needed to ask you about sex...”

Many heart patients are not only afraid to resume sex but also to talk about it, even when their spouse or partner is also suffering, as is the relationship. In its first-ever scientific statement on heart disease and sex, the American Heart Association says that following a heart attack, risk of death or a repeat heart attack is actually low, and encourages a meaningful dialogue between patients and their healthcare providers.

The AHA acknowledges that patients who've had a heart attack or stroke may face physical challenges such as decreased function and desire, along with mental challenges such as anxiety and depression. Additionally, medications such as fluid-reducing diuretics, those for chest pain or arrhythmia and some antidepressants can also affect sexual desire.

Sex is an important aspect of your quality of life, says guidelines coauthor and cardiologist Robert A. Kloner, M.D., Ph.D., professor at the University of Southern California's Keck School of Medicine in Los Angeles. Kloner is also research director at Good Samaritan Hospital in Los Angeles and attends at Los Angeles County Hospital, where he says the issue of sexual activity following a heart attack is often discussed.

The new guidelines compare sex to mild-to-moderate exercise. After extensive discussions and analyses, the guidelines' authors determined that after an “uncomplicated” heart attack, most patients with stable heart disease and “good functional capacity” may resume sexual activity in about a week. “Uncomplicated” means no heart failure, shock, severe arrhythmias or severe residual chest pain, Kloner explains. “Good functional capacity” means they're able to engage in other mild or moderate activity, such as walking for about 20 minutes or up two flights of stairs.

Before resuming sexual activity, patients should first undergo a complete history and physical exam. Those with unstable or severe symptoms must first be treated and stabilized.

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More than half of men age 60 or older develop erectile dysfunction, or ED. Having ED may predict future cardiovascular problems, says Kloner. “If you have ED, your chances of having a heart attack or stroke double,” he says.

Patients should be aware that ED is also associated with endothelial dysfunction, the “other ED.” With this condition, the inner lining of the body's blood vessels can't respond to the need for increased blood flow and oxygen delivery and can't dilate fully.

Men with endothelial dysfunction often have other vascular disorders, including atherosclerosis, which is the buildup of plaque in the arteries. Traditional risk factors for coronary heart disease, which include high cholesterol, high blood pressure, smoking, diabetes and eating a high-fat diet, have all been associated with impairments in endothelial function, which in turn may promote atherosclerosis.

Kloner says that men who have endothelial dysfunction along with sexual dysfunction often have treatable risk factors such as high blood pressure and high cholesterol. “[If you] treat those risk factors, you may save their lives,” he says.

Unfortunately, there haven't been a lot of studies done on sexual problems in women. “However, some studies suggest that the same risk factors that cause ED might be associated with sexual dysfunction in women, resulting in the inability of vessels in the female clitoris to [widen],” Kloner says. Vasodilation, or widening of vessels, helps provide adequate vaginal lubrication.

The AHA guidelines recommend that women with heart disease receive counseling about contraception and pregnancy when appropriate. Postmenopausal women may safely use estrogen creams, which are available in drugstores, on the vulva or in the vagina. Use of these creams is unlikely to pose any cardiac risk in women.

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Healthcare providers can do a better job of delivering comprehensive care that goes beyond a simple handout to the patient, says psychologist Stephen Josephson, Ph.D., clinical assistant professor at Cornell University Medical Center and faculty member at Columbia Medical Center in New York City.

Patients often say they don't have enough education about what to do about sex after a heart attack. This may be because of a healthcare provider's lack of knowledge, experience or comfort discussing sexual issues and limited time during a doctor's appointment. Research shows that sexual counseling can yield increased knowledge, a higher likelihood of return to sexual activity, improved sexual desire and satisfaction, more confidence and less fear in resuming sexual activity.

“The trauma of a heart attack, combined with medication patients believe will adversely impact sexual function, plus depression and anxiety, are all bad for sex,” Josephson says. “There's worry and there's avoidance—and heaven forbid if a patient then experiences an increased heart rate during sex, which he might interpret as a medical problem when it's anxiety.” That “panic” may further complicate sexual performance.

Patients should slowly return to both physical and sexual activity. It's valuable to do things that make them feel accomplished or pleasurable—not just in the bedroom, he says.

Therapy including cognitive “distancing” can prevent patients from embracing every negative thought about sex causing more heart problems. “Step back from the thoughts, and ‘project’ them onto a screen,” Josephson says. “If you have thoughts regarding possible erectile difficulties, you can simply note them and redirect attention to what's going on in bed.”

Know that performance anxiety doesn't only play out on stage. “Patients need realistic expectations,” he says. “The primary psychological cause of sexual dysfunction is perfectionism. In real life, not every couple gets turned on and has an orgasm at the same time. And as men get older, it just takes longer to achieve orgasm.”

As research shows, a loving relationship that's caring, open and honest can provide many of the benefits of sexual climax. “Frequently, when men are traumatized medically or have problems with sexual function, they stop holding hands and cuddling,” Josephson says. Both cuddling and caressing have been shown to be key components in the success of long-term relationships, as has the ability to talk about the relationship.

Don't keep quiet about your fears and concerns about sex after a heart attack. “Sustaining that awkwardness, that tension from different sides of the bed, is unhealthy,” Josephson says. “Very few people can live with that and be OK over time.”

Take the time to talk to your healthcare provider and your partner about the right time to return to intimacy. There's nothing to fear—having a heart attack doesn't have to mean giving up a healthy sex life.

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Big screen, big fears

Movie scenes during which a man dies while having sex can fuel unfounded fears. True, both heart rate and blood pressure rise during sex, but they aren't lethal weapons. Research shows that sexual activity in general is associated with an increased risk of cardiovascular events, but it's actually miniscule—less than 1 percent. And while great sex may temporarily feel like winning a marathon, during sex the body expends energy equal to walking one-half mile at a good clip or climbing two flights of stairs. In fact, earlier data show that anger is three times more likely to cause a heart attack than sex.

The AHA guidelines say that when sex does incite a cardiac event and subsequent death, it is typically in a male engaging in extra-marital sexual activity, with a younger partner in an unfamiliar setting and/or after excessive food and alcohol consumption. Dying while having sex is the exception rather than the rule.

Hollywood aside, millions of baby boomers pursuing “healthy aging” and erectile dysfunction or “ED”-focused television commercials for ED drugs have motivated in-office discussions of sexual dysfunction—and that's a good thing, Kloner says.

As advertisements caution, patients taking nitroglycerin tablets or other nitrates for angina or chest pain should avoid ED medications—the two drug categories can cause hypotension, a rapid drop in blood pressure.

© 2012 American Heart Association, Inc.