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First AHA advice on sexual activity and CVD

Comment by Uwe Nixdorff, EACPR Prevention, Epidemiology and Population Science Section


Sexual activity is an important component of patient and partner quality of life for men and women with cardiovascular disease (CVD). In spite of this there is reluctance addressing this issue in secondary prevention.
Actually there comes a first-ever scientific statement from the American Heart Association (AHA) on this issue (1). It is probably the most comprehensive on the subject to date and have been compiled by experts from various fields, including cardiology, exercise physiology, sexual counseling, and urology.

The main consent is that sexual activity is safe for the majority of CVD patients and that doctors as well as patients and their partners should endeavor to bring up the subject of sex. The first author of the statement, Dr. Glenn N Levine, comments in an interview to that “the important thing to emphasize is that the risk of heart attack with sexual activity is only extremely modestly increased and represents only a miniscule amount of a person´s overall risk.” The only patients who should refrain from sex are those with unstable, decompensated heart disease or severe symptoms (Class III; Level of Evidence C).

Numerous studies have examined the cardiovascular and neuroendocrine response to sexual arousal and intercourse, with most assessing male physiological responses during heterosexual vaginal intercourse. The greatest increases of systemic arterial blood pressure and heart rate occur during the 10 - 15 seconds of orgasm, with a rapid return to baseline thereafter. In young married men sexual activity is in the range of 3 – 4 metabolic equivalents (METS; i.e., the equivalent of climbing 2 flights of stairs or walking briskly) for a short duration. Thus, if a patient can achieve an energy expenditure of ≥ 3 METs without demonstrating ischemia during exercise testing the risk for ischemia during sexual activity is very low (Class IIa; Level of Evidence C). Heart rate rarely exceeds 130 bpm and systolic blood pressure rarely exceeds 170 mmHg in normotensives. Coital angina (“angina d´amour”) represents < 5% of all angina attacks and sexual activity is the cause of <1% of all acute MIs. Notably, the relative risk of myocardial infarction (MI) does not appear to be higher in subjects with a history of MI than in those without prior known coronary artery disease (CAD). However, sedentary individuals have a relative risk of coital MI of 3.0 – 4.4, whereas physically active individuals have a relative risk of 0.7 - 1.2 (2,3). 

At least it is reasonable that patients with CVD wishing to initiate or resume sexual activity be evaluated with a thorough medical history and physical examination (Class IIa; Level of Evidence C).
Further, sexual activity is reasonable for patients with CVD who, on clinical evaluation, are determined to be at low risk of cardiovascular complications (Class IIa; Level of Evidence B).
It is also reasonable after complete coronary revascualization (Class IIa; Level of Evidence B) and may be resumed several days after PCI if the vascular access site is without complications (Class IIa; Level of Evidence C) or 6 – 8 weeks after standard CABG (considerable stress on chest and breathing generating high intrathoracic pressures that could compromise sternal wound healing), provided the sternotomy is well healed (Class IIa; Level of Evidence B).
Notably, sexual activity is judged reasonable already 1 week after uncomplicated MI if the patient is without cardiac symptoms during mild to moderate physical activity (Class IIa; Level of Evidence C), which is in accordance to the 2004 ACC/AHA Guidelines for the  Management of Patients with ST-elevation Myocardial Infarction (4).

Psychological distress and decreased sexual function or activity are associated and are common in patients with CVD. Anxiety and depression regarding sexual activity should be assessed in patients (Class I; Level of Evidence B).

It is also stressed that the use of phoshodiesterase-5 (PDE-5) inhibitors erectile-dysfunction drugs, such as sildenafil are generally safe for men who have stable CVD. Otherwise, those agents are absolutely contraindicated in patients receiving nitrate therapy, either long-acting preparations or sublingual ones (Class III; Level of Evidence B).

Sexual counseling is rarely provided. Potential reasons for this include the provider´s lack of experience or comfort discussing sexual issues, inadequate knowledge on issues regarding sexual activity and CVD, and limited time (5).

Therefore it is stated that patient and spouse/partner counseling by healthcare providers is useful to assist in resumption of sexual activity after an acute cardiac event, new CVD diagnosis, or ICD implantation (Class I; Level of Evidence B).


  1. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association.
    Levine GN, et al.
    Circulation 2012; 125; ahead of print online January 19th, 2012.
  2. Determinants of Myocardial Infarction Onset Study Investigators. Triggering myocardial infarction by sexual activity: low absolute risk and prevention by regular physical exertion.
    Muller JE, et al.
    JAMA 1996; 275:1405-9.
  3. Sexual activity as a trigger of myocardial infarction: a case-crossover analysis in the Stockholm Heart Epidemiology Programme (SHEEP).
    Möller J, et al.
    Heart 2001; 86:387-90.
  4. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guideline.
    Antman EM, et al.
    Circulation 2005; 111:2013-4.
  5. UNITE Research Group. Sexual counseling of cardiac patients: nurses´ perception of practice, responsibility and confidence.
    Jaarsma T, et al.
    Eur J Cardiovasc Nurs 2010; 9:24-9.