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Managing Sexual Dysfunction in Cardiac Patients

Am Fam Physician. 2000 Dec 1;62(11):2505-2506.

Sexual dysfunction problems are widespread and have an adverse effect on mood, well-being and interpersonal functioning. Erectile dysfunction (ED) is the most commonly recognized and treated sexual dysfunction; it affects more than 30 percent of men 40 to 70 years of age. The prevalence of ED is higher among men with cardiovascular disease. Current therapies for ED are safe and effective in the majority of patients with or without cardiovascular disease, although sildenafil is always contraindicated in patients taking nitrate-containing medications.

DeBusk and associates discuss concerns about the risk of sexual activity triggering acute significant cardiac events. The American Heart Association/American College of Cardiology (AHA/ACC) Expert Consensus Document published in 1999 addressed the use of sildenafil in men with cardiovascular disease. To update this body of information and to review the cardiac risk associated with sexual activity, an international consensus conference was held in June 1999. This multidisciplinary meeting determined that a wide variability in physiologic response to sexual activity exists that is further affected by the type of sexual activity and familiarity with the partner. Generally, sexual activity is similar to mild-to-moderate intensity exercise for most people with or without coronary artery disease with heart rates rarely exceeding 130 beats per minute and systolic blood pressure rarely greater than 170 mm Hg.

The risk of myocardial infarction during or up to two hours following sexual activity is two-and-one-half times higher than during nonsexual activities. This relative risk was three times higher in men with a previous history of myocardial infarction; however, the absolute risk still remains very low. Patients can be placed into one of three grades of risk (see the accompanying table). Patients in the intermediate risk group require cardiovascular assessment to determine whether they should be reassigned to the low-risk or high-risk category.

Management Recommendations Based on Graded Cardiovascular Risk Assessment

Grade of risk and categories of cardiovascular disease Recommendations

Low risk

Asymptomatic, <3 major risk factors for CAD; controlled hypertension; mild, stable angina; post-successful coronary revascularization; uncomplicated past MI (>6 to 8 weeks); mild valvular disease; LVD/CHF (NYHA class I)

Primary care management; consider all first-line therapies; reassess at regular intervals (6 to 12 months)

Intermediate risk

≥ 3 major risk factors for CAD, excluding gender; moderate, stable angina; recent MI (>2, <6 weeks); LVD/CHF (NYHA class II); noncardiac sequelae of atherosclerotic disease (e.g., CVA, peripheral vascular disease)

Specialized CV testing (e.g., ETT, Echo); restratification into high risk or low risk based on the results of CV assessment

High risk

Unstable or refractory angina; uncontrolled hypertension; LVD/CHF (NYHA class III/IV); recent MI (<2 weeks), CVA; high-risk arrhythmias; hypertrophic obstructive and other cardiomyopathies; moderate/severe valvular disease

Priority referral for specialized CV management; treatment for sexual dysfunction to be deferred until cardiac condition is stabilized and depends on specialist recommendations


CAD = coronary artery disease; MI = myocardial infarction; LVD = left ventricular dysfunction; CHF = congestive heart failure; NYHA = New York Heart Association; CV = cardiovascular; CVA = cerebral vascular accident; ETT = exercise tolerance test; Echo = echocardiogram.

Adapted with permission from DeBusk R, Drory Y, Goldstein I, Jackson G, Kaul S, Kimmel SE, et al. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel. Am J Cardiol 2000;86:178.

Management Recommendations Based on Graded Cardiovascular Risk Assessment

View Table

Management Recommendations Based on Graded Cardiovascular Risk Assessment

Grade of risk and categories of cardiovascular disease Recommendations

Low risk

Asymptomatic, <3 major risk factors for CAD; controlled hypertension; mild, stable angina; post-successful coronary revascularization; uncomplicated past MI (>6 to 8 weeks); mild valvular disease; LVD/CHF (NYHA class I)

Primary care management; consider all first-line therapies; reassess at regular intervals (6 to 12 months)

Intermediate risk

≥ 3 major risk factors for CAD, excluding gender; moderate, stable angina; recent MI (>2, <6 weeks); LVD/CHF (NYHA class II); noncardiac sequelae of atherosclerotic disease (e.g., CVA, peripheral vascular disease)

Specialized CV testing (e.g., ETT, Echo); restratification into high risk or low risk based on the results of CV assessment

High risk

Unstable or refractory angina; uncontrolled hypertension; LVD/CHF (NYHA class III/IV); recent MI (<2 weeks), CVA; high-risk arrhythmias; hypertrophic obstructive and other cardiomyopathies; moderate/severe valvular disease

Priority referral for specialized CV management; treatment for sexual dysfunction to be deferred until cardiac condition is stabilized and depends on specialist recommendations


CAD = coronary artery disease; MI = myocardial infarction; LVD = left ventricular dysfunction; CHF = congestive heart failure; NYHA = New York Heart Association; CV = cardiovascular; CVA = cerebral vascular accident; ETT = exercise tolerance test; Echo = echocardiogram.

Adapted with permission from DeBusk R, Drory Y, Goldstein I, Jackson G, Kaul S, Kimmel SE, et al. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel. Am J Cardiol 2000;86:178.

The authors conclude that stratification of patients into low, intermediate and high levels of cardiac risk can help guide physicians managing patients who are resuming sexual activity. The large majority of patients will be in the low-risk group and safely can be encouraged to initiate or resume sexual activity or to receive treatment for sexual dysfunction. Those at intermediate risk should receive further cardiologic evaluation for restratification into low-risk or high-risk groups. Patients in the high-risk category should be stabilized before resumption of sexual activity or initiation of treatment for sexual dysfunction. Follow-up at regular intervals (e.g., every six months) and reassessment are recommended for all patients receiving treatment for sexual dysfunction.

DeBusk R, et al. Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel. Am J Cardiol. July 15, 2000;86:175–81.

editor's note: Much concern exists regarding resumption of sexual activity in men who were sedentary, particularly when cardiovascular disease was present. Further research has determined that, although there is a slightly higher risk of myocardial infarction during the two hours immediately following sexual activity, this increased risk is very low in patients with and without prior evidence of coronary artery disease. Although there is some variation depending on familiarity with the partner and the physical nature of the sexual act, the metabolic energy expended during sexual activity is lower than that expended in many ordinary daily activities, and heart rate usually remains below 130 beats per minute. If concern exists about the added stress of a more active sex life, a stress test can readily identify at-risk patients.—r.s.

 

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