For heart patients with elevated or unknown cardiovascular risk, a stress test should take place before the resumption of sexual activity. If patients achieve a safe load of more than three to five metabolic equivalents (MET) without difficulties and without abnormal ECG changes, sex is no danger, it says in the paper. Recommendations for the assessment of physical fitness for sex are given here for different groups of cardiac patients. The physical impact of sexual activity is classified as moderate.
The load to which the cardiovascular system is exposed is comparable to that of going two storeys up a flight of stairs, or of a walk at rapid pace. Patients with cardiovascular disease who do not end up out of breath after these physical activities would, therefore, even during coitus only have a minor risk of oxygen deficiency. A systolic blood pressure above 170 mmHg or a pulse of 130/minute is exceeded only rarely – at least this is the case for otherwise normotensive men who are having sex with their own wives. In general, the physical load associated with sexual activity is in the range of three to five metabolic equivalent units (MET), depending on age, fitness and overall state of health. The blood pressure and heart rate rise most sharply in the 10 to 15 seconds during orgasm and to a slight extent during foreplay.
As expected, there is an increased risk of cardiovascular complication during coitus. The absolute event rate is nevertheless tiny, according to the AHA, mainly because the stress usually only lasts a few seconds. Even having already suffered a previous heart attack is therefore not a contraindication for physical love. One hour of sex per week increased the risk of a new myocardial infarction or death for a short moment from 10 in a million to 20 or 30 in a million cases for these patients. As such, less than one percent of all heart attacks and cases of sudden death occur during sexual intercourse. “Angina d’amour” occurring during intercourse, or in the hours following, accounts for less than five percent of all angina pectoris seizures. But what about individual, cardiovascular-disease patients?
The specific sex recommendations
In answering these questions, the current AHA publication will help. Experts from various disciplines have therein coalesced the published data and the guidelines derived from large medical communities and made the following recommendations:
- Before patients with newly identified CVD become sexually active again, a careful medical amnesis and physical examination should take place. If there is a low risk of cardiovascular complications, there is nothing that speaks against sex.
- When the cardiovascular risk is not low or is unknown, a stress test is recommended. Sexual activity is no source of problem if patients manage at least 3-5 METs, without angina, excessive dyspnea, ischemic ST changes, cyanosis, hypotension or arrhythmias occurring.
- The risk of cardiovascular complications coming from sex can be reduced through cardiac rehabilitation and sports.
- Patients with unstable and /or decompensated CVD should refrain from sexual activities until these are stabilised and treated optimally. The same applies for patients with cardiovascular ailments which have actually been provoked by sexual activity.
- Concerns about potential adverse effects on sexuality must not be a reason for doing without prescription of symptomatic and/or prognostically effective cardiovascular drugs.
- Drugs for the treatment of erectile dysfunction (PDE-5 inhibitors) are considered to be safe in stable cardiovascular disease. PDE-5 inhibitors, however, are prohibited if the patient consumes nitrates. Conversely, patients taking PDE-5 inhibitors then (depending on the substance) cannot take in any nitrates for 24-48 hours.
- Premenopausal women with CVD should be given advice with respect to the safety of contraceptives and pregnancy.
- Postmenopausal women with CVD should receive no systemic oestrogen in the treatment of dyspareunia.
- After a cardinal event, with newly diagnosed cases of CVD and after the implantation of a defibrillator the topic of “sex” should be addressed as part of the medical consultation.
A complete sex life is an important factor in the quality of life of patients and in partner relationships, and for most patients suffering from CVD it is purposeful to have an active sex life. However, it is recommended that for CVD patients a full medical history be assembled and that they have a comprehensive physical examination carried out in advance. In patients with stable symptoms and good sustainable physical capacities, there is no reason to abstain from sexual activity. Patients with unstable or severe symptoms should first be treated and have these stabilised before they permit themselves sexual activity.