Sexual activity in patients with cardiovascular disease
- William H Sauer, MD
William H Sauer, MD
- Associate Professor of Medicine
- University of Colorado School of Medicine
- Stephen E Kimmel, MD, MS
Stephen E Kimmel, MD, MS
- Associate Professor of Medicine and Epidemiology
- University of Pennsylvania
- Section Editor
- Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
Juan Carlos Kaski, DSc, MD, DM (Hons), FRCP, FESC, FACC, FAHA
- Section Editor — Coronary Heart Disease
- Professor of Cardiovascular Science
- Director, Cardiovascular and Cell Sciences Research Institute
- St. George's, University of London
- Deputy Editors
- Howard Libman, MD, FACP
Howard Libman, MD, FACP
- Deputy Editor — Primary Care (Adult)
- Professor of Medicine, Emeritus
- Harvard Medical School
- Gordon M Saperia, MD, FACC
Gordon M Saperia, MD, FACC
- Senior Deputy Editor — UpToDate
- Deputy Editor — Cardiovascular Medicine
- Assistant Professor of Medicine
- Tufts University School of Medicine
Sexual activity is an important component of quality of life and thus is of great concern for both patients with heart disease and their physicians. Cardiac patients are often fearful of triggering myocardial infarction (MI) during intercourse and may therefore have sex less frequently. Another component of this problem is that patients seeking medical attention for sexual dysfunction often have concomitant cardiovascular disease.
Several aspects of the sex-MI relationship will be discussed here, including the cardiovascular effects of sexual activity, the association between sex and MI, modulating factors that may decrease the risk of MI following sexual activity, and the treatment options for cardiac patients with sexual dysfunction. The risk in patients with other cardiovascular diseases will also be mentioned.
CARDIOVASCULAR EFFECTS OF SEXUAL ACTIVITY
Sexual activity, including arousal, erection, ejaculation, orgasm, refractory period, and resolution, is in part dependent upon changes in the autonomic nervous system.
●Sexual arousal and penile erection in men results from stimulation of parasympathetic nerves in the penis, reduced activity of sympathetic pathways, and the release of nitric oxide from the endothelium . The importance of nitric oxide constitutes the rationale for the use of sildenafil in men with sexual dysfunction. (See 'Sildenafil' below and "Overview of male sexual dysfunction", section on 'Role of blood flow and nitric oxide'.)
●Early sexual arousal in women appears to result from sympathetic nervous system activation . (See "Sexual dysfunction in women: Epidemiology, risk factors, and evaluation".)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Rampin O, Giuliano F. Central control of the cardiovascular and erection systems: possible mechanisms and interactions. Am J Cardiol 2000; 86:19F.
- Meston CM. Sympathetic nervous system activity and female sexual arousal. Am J Cardiol 2000; 86:30F.
- Masters, WH, Johnson, VE. Human sexual response, Little, Brown, and Co, Boston 1966.
- BARTLETT RG Jr. Physiologic responses during coitus. J Appl Physiol 1956; 9:469.
- Hellerstein HK, Friedman EH. Sexual activity and the postcoronary patient. Arch Intern Med 1970; 125:987.
- Nemec ED, Mansfield L, Kennedy JW. Heart rate and blood pressure responses during sexual activity in normal males. Am Heart J 1976; 92:274.
- Bohlen JG, Held JP, Sanderson MO, Patterson RP. Heart rate, rate-pressure product, and oxygen uptake during four sexual activities. Arch Intern Med 1984; 144:1745.
- DeBusk RF. Evaluating the cardiovascular tolerance for sex. Am J Cardiol 2000; 86:51F.
- Stein RA. Cardiovascular response to sexual activity. Am J Cardiol 2000; 86:27F.
- Stein RA. The effect of exercise training on heart rate during coitus in the post myocardial infarction patient. Circulation 1977; 55:738.
- Muller JE, Mittleman MA, Maclure M, et al. Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical exertion. Determinants of Myocardial Infarction Onset Study Investigators. JAMA 1996; 275:1405.
- Möller J, Ahlbom A, Hulting J, et al. Sexual activity as a trigger of myocardial infarction. A case-crossover analysis in the Stockholm Heart Epidemiology Programme (SHEEP). Heart 2001; 86:387.
- Jackson G. Sexual intercourse and angina pectoris. Int Rehabil Med 1981; 3:35.
- Muller JE. Triggering of cardiac events by sexual activity: findings from a case-crossover analysis. Am J Cardiol 2000; 86:14F.
- Kimmel SE. Sex and myocardial infarction: an epidemiologic perspective. Am J Cardiol 2000; 86:10F.
- Rothenbacher D, Dallmeier D, Mons U, et al. Sexual Activity Patterns Before Myocardial Infarction and Risk of Subsequent Cardiovascular Adverse Events. J Am Coll Cardiol 2015; 66:1516.
- Mittleman MA, Maclure M, Tofler GH, et al. Triggering of acute myocardial infarction by heavy physical exertion. Protection against triggering by regular exertion. Determinants of Myocardial Infarction Onset Study Investigators. N Engl J Med 1993; 329:1677.
- Albert CM, Mittleman MA, Chae CU, et al. Triggering of sudden death from cardiac causes by vigorous exertion. N Engl J Med 2000; 343:1355.
- Muller JE, Tofler GH, Stone PH. Circadian variation and triggers of onset of acute cardiovascular disease. Circulation 1989; 79:733.
- Muller JE, Abela GS, Nesto RW, Tofler GH. Triggers, acute risk factors and vulnerable plaques: the lexicon of a new frontier. J Am Coll Cardiol 1994; 23:809.
- Mittleman MA, Maclure M, Sherwood JB, et al. Triggering of acute myocardial infarction onset by episodes of anger. Determinants of Myocardial Infarction Onset Study Investigators. Circulation 1995; 92:1720.
- Ridker PM, Manson JE, Buring JE, et al. Circadian variation of acute myocardial infarction and the effect of low-dose aspirin in a randomized trial of physicians. Circulation 1990; 82:897.
- Kostis JB, Jackson G, Rosen R, et al. Sexual dysfunction and cardiac risk (the Second Princeton Consensus Conference). Am J Cardiol 2005; 96:313.
- Feldman HA, Johannes CB, Derby CA, et al. Erectile dysfunction and coronary risk factors: prospective results from the Massachusetts male aging study. Prev Med 2000; 30:328.
- Jackson G. Erectile dysfunction and cardiovascular disease. Int J Clin Pract 1999; 53:363.
- Virag R, Bouilly P, Frydman D. Is impotence an arterial disorder? A study of arterial risk factors in 440 impotent men. Lancet 1985; 1:181.
- Drory Y, Kravetz S, Florian V, Weingarten M. Sexual activity after first acute myocardial infarction in middle-aged men: demographic, psychological and medical predictors. Cardiology 1998; 90:207.
- Renshaw DC, Karstaedt A. Is there (sex) life after coronary bypass? Compr Ther 1988; 14:61.
- Rosal MC, Downing J, Littman AB, Ahern DK. Sexual functioning post-myocardial infarction: effects of beta-blockers, psychological status and safety information. J Psychosom Res 1994; 38:655.
- Papadopoulos C, Beaumont C, Shelley SI, Larrimore P. Myocardial infarction and sexual activity of the female patient. Arch Intern Med 1983; 143:1528.
- Drory Y, Kravetz S, Weingarten M. Comparison of sexual activity of women and men after a first acute myocardial infarction. Am J Cardiol 2000; 85:1283.
- Dhabuwala CB, Kumar A, Pierce JM. Myocardial infarction and its influence on male sexual function. Arch Sex Behav 1986; 15:499.
- Papadopoulos C, Shelley SI, Piccolo M, et al. Sexual activity after coronary bypass surgery. Chest 1986; 90:681.
- Oskay U, Can G, Camcı G. Effect of myocardial infarction on female sexual function in women. Arch Gynecol Obstet 2015; 291:1127.
- Petrie KJ, Weinman J, Sharpe N, Buckley J. Role of patients' view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study. BMJ 1996; 312:1191.
- Goldstein I. The mutually reinforcing triad of depressive symptoms, cardiovascular disease, and erectile dysfunction. Am J Cardiol 2000; 86:41F.
- Friedman S. Cardiac disease, anxiety, and sexual functioning. Am J Cardiol 2000; 86:46F.
- Roose SP, Seidman SN. Sexual activity and cardiac risk: is depression a contributing factor? Am J Cardiol 2000; 86:38F.
- Papadopoulos C, Larrimore P, Cardin S, Shelley SI. Sexual concerns and needs of the postcoronary patient's wife. Arch Intern Med 1980; 140:38.
- Roviaro S, Holmes DS, Holmsten RD. Influence of a cardiac rehabilitation program on the cardiovascular, psychological, and social functioning of cardiac patients. J Behav Med 1984; 7:61.
- Kloner RA. Cardiovascular risk and sildenafil. Am J Cardiol 2000; 86:57F.
- Adverse reactions to bendrofluazide and propranolol for the treatment of mild hypertension. Report of Medical Research Council Working Party on Mild to Moderate Hypertension. Lancet 1981; 2:539.
- Grimm RH Jr, Grandits GA, Prineas RJ, et al. Long-term effects on sexual function of five antihypertensive drugs and nutritional hygienic treatment in hypertensive men and women. Treatment of Mild Hypertension Study (TOMHS). Hypertension 1997; 29:8.
- Bruckert E, Giral P, Heshmati HM, Turpin G. Men treated with hypolipidaemic drugs complain more frequently of erectile dysfunction. J Clin Pharm Ther 1996; 21:89.
- Kloner RA. Cardiovascular effects of the 3 phosphodiesterase-5 inhibitors approved for the treatment of erectile dysfunction. Circulation 2004; 110:3149.
- Conti CR, Pepine CJ, Sweeney M. Efficacy and safety of sildenafil citrate in the treatment of erectile dysfunction in patients with ischemic heart disease. Am J Cardiol 1999; 83:29C.
- Goldstein I, Lue TF, Padma-Nathan H, et al. Oral sildenafil in the treatment of erectile dysfunction. Sildenafil Study Group. N Engl J Med 1998; 338:1397.
- Herrmann HC, Chang G, Klugherz BD, Mahoney PD. Hemodynamic effects of sildenafil in men with severe coronary artery disease. N Engl J Med 2000; 342:1622.
- Webb DJ, Freestone S, Allen MJ, Muirhead GJ. Sildenafil citrate and blood-pressure-lowering drugs: results of drug interaction studies with an organic nitrate and a calcium antagonist. Am J Cardiol 1999; 83:21C.
- Kloner RA, Jarow JP. Erectile dysfunction and sildenafil citrate and cardiologists. Am J Cardiol 1999; 83:576.
- Halcox JP, Nour KR, Zalos G, et al. The effect of sildenafil on human vascular function, platelet activation, and myocardial ischemia. J Am Coll Cardiol 2002; 40:1232.
- Kloner RA, Hutter AM, Emmick JT, et al. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol 2003; 42:1855.
- Borer J, Armstrong P, Food and Drug Administration Cardiovascular and Renal Drugs Advisory Committee. Proceedings of the 99th meeting of the Food and Drug Administration Cardiovascular and Renal Drugs Advisory Committee. May 29th and 30th, 2003. Circulation 2003; 107:e9052.
- Webb DJ, Muirhead GJ, Wulff M, et al. Sildenafil citrate potentiates the hypotensive effects of nitric oxide donor drugs in male patients with stable angina. J Am Coll Cardiol 2000; 36:25.
- Kloner RA, Brown M, Prisant LM, Collins M. Effect of sildenafil in patients with erectile dysfunction taking antihypertensive therapy. Sildenafil Study Group. Am J Hypertens 2001; 14:70.
- Pickering TG, Shepherd AM, Puddey I, et al. Sildenafil citrate for erectile dysfunction in men receiving multiple antihypertensive agents: a randomized controlled trial. Am J Hypertens 2004; 17:1135.
- Feenstra J, van Drie-Pierik RJ, Laclé CF, Stricker BH. Acute myocardial infarction associated with sildenafil. Lancet 1998; 352:957.
- Arora RR, Timoney M, Melilli L. Acute myocardial infarction after the use of sildenafil. N Engl J Med 1999; 341:700.
- Ishikura F, Beppu S, Hamada T, et al. Effects of sildenafil citrate (Viagra) combined with nitrate on the heart. Circulation 2000; 102:2516.
- Mittleman MA, Maclure M, Glasser DB. Evaluation of acute risk for myocardial infarction in men treated with sildenafil citrate. Am J Cardiol 2005; 96:443.
- Morales A, Gingell C, Collins M, et al. Clinical safety of oral sildenafil citrate (VIAGRA) in the treatment of erectile dysfunction. Int J Impot Res 1998; 10:69.
- Shakir SA, Wilton LV, Boshier A, et al. Cardiovascular events in users of sildenafil: results from first phase of prescription event monitoring in England. BMJ 2001; 322:651.
- Bush HS. Safe use of sildenafil in patients with coronary artery disease. Cleve Clin J Med 2001; 68:349, 352.
- DeBusk RF, Pepine CJ, Glasser DB, et al. Efficacy and safety of sildenafil citrate in men with erectile dysfunction and stable coronary artery disease. Am J Cardiol 2004; 93:147.
- Arruda-Olson AM, Mahoney DW, Nehra A, et al. Cardiovascular effects of sildenafil during exercise in men with known or probable coronary artery disease: a randomized crossover trial. JAMA 2002; 287:719.
- Stauffer JC, Ruiz V, Morard JD. Subaortic obstruction after sildenafil in a patient with hypertrophic cardiomyopathy. N Engl J Med 1999; 341:700.
- Cheitlin MD, Hutter AM Jr, Brindis RG, et al. ACC/AHA expert consensus document. Use of sildenafil (Viagra) in patients with cardiovascular disease. American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999; 33:273.
- Wallis RM, Corbin JD, Francis SH, Ellis P. Tissue distribution of phosphodiesterase families and the effects of sildenafil on tissue cyclic nucleotides, platelet function, and the contractile responses of trabeculae carneae and aortic rings in vitro. Am J Cardiol 1999; 83:3C.
- Geelen P, Drolet B, Rail J, et al. Sildenafil (Viagra) prolongs cardiac repolarization by blocking the rapid component of the delayed rectifier potassium current. Circulation 2000; 102:275.
- Vaidyanathan S, Krishnan KR. Myocardial infarction associated with intra-cavernosal administration of alprostadil in a patient with spinal cord injury and paraplegia. Spinal Cord 1996; 34:754.
- Gamel C, Davis BD, Hengeveld M. Nurses' provision of teaching and counselling on sexuality: a review of the literature. J Adv Nurs 1993; 18:1219.
- Steinke EE, Jaarsma T, Barnason SA, et al. Sexual counseling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP). Circulation 2013; 128:2075.
- Levine GN, Steinke EE, Bakaeen FG, et al. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation 2012; 125:1058.
- CARDIOVASCULAR EFFECTS OF SEXUAL ACTIVITY
- Hemodynamic stress
- Response in stable angina
- RISK OF MI AFTER SEX
- Modulation of risk
- - Regular exercise
- - Medical therapy
- RISK OF SEXUAL ACTIVITY
- Risk assignment
- - Low risk
- - Intermediate or indeterminate risk
- - High risk
- SEXUAL DYSFUNCTION POST-MI
- TREATMENT OF SEXUAL DYSFUNCTION
- General principles
- PDE-5 inhibitors
- - Sildenafil
- - Vardenafil and tadalafil
- - Adverse interaction with nitrates
- - Antihypertensive drugs
- - Does sildenafil promote MI?
- - Other potential problems
- Other therapies
- SEXUAL COUNSELING
- RECOMMENDATIONS OF OTHERS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS