Summary
Sexual activity is an important component of patient and partner quality of life, and it is reasonable for most patients with CVD to engage in sexual activity.
It is reasonable that patients with CVD who wish to engage in sexual activity undergo a comprehensive history and physical examination beforehand.
Those with stable symptoms and good functional capacity generally have a low risk of adverse cardiovascular events with sexual activity.
Patients with unstable or severe symptoms should first be treated and stabilized before engaging in sexual activity.
Exercise testing can provide additional information as to the safety of sexual activity in patients with indeterminate or unclear risk.
Cardiovascular medications are uncommonly the true cause of ED, and those that can improve symptoms and survival should not be withheld because of concerns about the potential impact on sexual function. PDE5 inhibitors have proved safe and effective in many patients with stable CVD; however, nitrate use is an absolute contraindication for PDE5 inhibitor administration.
Anxiety and depression are important considerations in patients with CVD and can contribute to reduced or impaired sexual activity.
Sexual counseling of CVD patients and their partners is an important component of recovery; unfortunately, it is rarely provided.
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 or have unknown cardiovascular risk to assess exercise capacity and development of symptoms, ischemia, or arrhythmias
5. Sexual activity is reasonable for patients who can exercise >3 to 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 activity until their condition is stabilized and optimally managed
Sexual Activity and Specific Cardiovascular Conditions
Coronary Artery Disease Recommendations
1. Sexual activity is reasonable for patients with no or mild angina
2. Sexual activity is reasonable 1 or more weeks after uncomplicated MI if the patient is without cardiac symptoms during mild to moderate physical activity
3. Sexual activity is reasonable for patients who have undergone complete coronary revascularization, and, may be resumed (a) several days after percutaneous coronary intervention (PCI) if the vascular access site is without complications or (b) 6 to 8 weeks after standard coronary artery bypass graft surgery (CABG), provided the sternotomy is well healed
4. Sexual activity is reasonable for patients who have undergone noncoronary open heart surgery and may be resumed 6 to 8 weeks after the procedure,provided the sternotomy is well healed
5. For patients with incomplete coronary revascularization, exercise stress testing can be considered to assess the extent and severity of residual ischemia
6. Sexual activity should be deferred for patients with unstable or refractory angina until their condition is stabilized and optimally managed
Valvular Heart Disease Recommendations
1. Sexual activity is reasonable for patients with mild or moderate valvular heart disease and no or mild symptoms
2. Sexual activity is reasonable for patients with normally functioning prosthetic valves, successfully repaired valves, and successful transcatheter valve interventions
3. Sexual activity is not advised for patients with severe or significantly symptomatic valvular disease until their condition is stabilized and optimally managed
Heart Failure Recommendations
1. Sexual activity is reasonable for patients with compensated and/or mild (NYHA class I or II) heart failure
2. Sexual activity is not advised for patients with decompensated or advanced (NYHA class III or IV) heart failure until their condition is stabilized and optimally managed .
Congenital Heart Disease Recommendation
1. Sexual activity is reasonable for most CHD patients who do not have decompensated or advanced heart failure, severe and/or significantly symptomatic valvular disease, or uncontrolled arrhythmias.
Hypertrophic Cardiomyopathy Recommendations
2. Sexual activity should be deferred for patients with HCM who are severely symptomatic until their condition is stabilized
Arrhythmias, Pacemakers, and ICDs Recommendations
1. Sexual activity is reasonable for patients with atrial fibrillation or atrial flutter and well-controlled ventricular rate
2. Sexual activity is reasonable for patients with a history of atrioventricular nodal reentry tachycardia, atrioventricular reentry tachycardia, or atrial tachycardia with controlled arrhythmias
3. Sexual activity is reasonable for patients with pacemakers
4. Sexual activity is reasonable for patients with an ICD implanted for primary prevention).
5. Sexual activity is reasonable for patients with an ICD used for secondary prevention in whom moderate physical activity (>3–5 METS) does not precipitate ventricular tachycardia or fibrillation and who do not receive frequent multiple appropriate shocks
6. Sexual activity should be deferred for patients with atrial fibrillation and poorly controlled ventricular rate, uncontrolled or symptomatic supraventricular arrhythmias, and spontaneous or exercise-induced ventricular tachycardia until the condition is optimally managed .
7. Sexual activity should be deferred in patients with an ICD who have received multiple shocks until the causative arrhythmia is stabilized and optimally controlled.
Cardiovascular Drugs and Sexual Function Recommendation
1. Cardiovascular drugs that can improve symptoms and survival should not be withheld because of concerns about the potential impact on sexual function
Pharmacotherapy for Sexual Dysfunction PDE5 Inhibitors Recommendations
1. PDE5 inhibitors are useful for the treatment of ED in patients with stable CVD
2. The safety of PDE5 inhibitors is unknown in patients with severe aortic stenosis or HCM
3. PDE5 inhibitors should not be used in patients receiving nitrate therapy
4. Nitrates should not be administered to patients within 24 hours of sildenafil or vardenafil administration or within 48 hours of tadalafil administration
Herbal Medications Recommendation
1. It may be reasonable to caution patients with CVD regarding the potential for adverse events with the use of herbal medications with unknown ingredients that are taken for treatment of sexual dysfunction
Psychological Issues of Sexual Activity and CVD Recommendation
1. Anxiety and depression regarding sexual activity should be assessed in patients with CVD
Patient and Partner Counseling Recommendation
1. 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
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