Sex

After Heart Disease

Tuko Srimulyo
2
Sex After ACS
• Sexual activity is important component of patient and partner quality of life for
men and women with CVD, including many elderly patients  anxiety and
depression
• Sexual activity is the cause of < 1% of all ACS.
• The absolute risk increase for ACS associated with 1 hour of sexual activity per
week  2 to 3 per 10 000 person years.
• Individuals with higher habitual sexual activity levels experience smaller increases
in risk than individuals with low activity levels
• SHEEP study of post-ACS patients (50% women) similarly found that those who
were sedentary had a higher risk of ACS with sexual activity (RR= 4.4) than did
those who were physically active (RR= 0.7)
.

Muller et al, 1966; Moller et al., 2001; Dahabreh et al, 2011; Levine et al, 2012
3
Human Sexual Response Cycle

Xue-rui et al, 2008

4
Cardiac Change during Sex

• The mean BP at coital is 162/89 mmHg and the mean value

of body oxygen consumption was 16 ml O2/min/kg
• HR during sexual activity might reach 140-180 bpm, SBP
increased by 80 mmHg and DBP by 50 mmHg on average
• Sexual activity is often equal to 2 to 3 METs in preorgasmic
phase and 3 to 4 METs in orgasmic phase.

Xue-rui et al, 2008 ; Levine et al, 2012

5
Cardiac Change during Sex

Xue-rui et al, 2008

6
Cardiac Change during Sex

Xue-rui et al, 2008

7
 Coital Angina ?

• Angina that occurs during the minutes or hours after sexual

activity.
• < 5% of all anginal attacks
• It is rare in patients who do not have angina during
strenuous physical exertion and more prevalent in sedentary
individuals with severe CAD who experience angina with
minimal physical activity.
• Can manage with precoital nitrates

Levine et al, 2012

8
 When To Resume Sexual
Activity After ACS?

• Sexual intercourse should be safe if a patient can perform an

activity equal to 5-6 METs such as climbing 20 stairs in 10-15
seconds without distress or 2-4 Flights without chest pain, >
400 m 6 MWT, >5-5.5 mnt treadmill)
• Post infarction patients who reach 5-6 METs on stress testing
without ischemia or arrhythmia can resume their normal
sexual activity without risk.
• Most of patients able to resume sexual activity within 4
weeks.

Levine et al, 2012

9
10
SEXUAL ACTIVITY VS WALKING
COMPARING EFFORTS

Araujo et al, 2015

11
Algorithm to sexual activity

Araujo et al, 2015

12
Sexual Activity and Stable Ischemic
Heart Disease

For patients with stable ischemic heart disease, evaluation of their

cardiovascular risk before they initiate or resume sexual activity is
reasonable.
Exercise testing may
(1) provide an objective assessment of exercise tolerance and
capacity;
(2) determine whether angina occurs with exertion (and at what level
of exertion); and
(3) assess the severity of ischemia with physical activity.

Levine et al, 2012

13
Sexual Activity post PCI

The cardiovascular risk of sexual activity after PCI is likely

related to the adequacy of coronary revascularization.
Patients with complete revascularization should be able to
resume sexual activity within days of PCI, provided there are
no complications related to femoral vascular access.
In patients with incomplete coronary revascularization,
exercise stress testing may be of benefit in assessing the
extent and severity of residual ischemia.

Levine et al, 2012

14
Sexual Activity and Heart Failure

Hemodynamic, vascular, hormonal, and neurohormonal abnormalities may contribute

to the sexual dysfunction that commonly occurs in heart failure patients.

Approximately 60% to 87% of heart failure patients report sexual problems,

Many heart failure patients place greater importance on improving quality of

life(including sexual activity) than on improving survival.

Optimal medical treatment and exercise training increases the likelihood of safe and
satisfactory sexual activity.

Can be advised to use “on-bottom” position during coitus, which decreases the level of
physical exertion, and to rest if dyspnea occurs.

Rastogi S, et al. Int J Impot Res. 2005; 17(suppl 1):S25–S36.

15
Jangan menolak terus dong, sex pada HF itu aman
sayangku....
16
17
 Drug for Sexual Dysfunction
Recommendation?
• Low- risk patient with erectile dysfunction can be safely treated
with PDE-5 inhibitor
• Patient should be cautioned about the contraindication between
PDE 5 inhibitor and nitrates.
• Nitrates should not be administered to patients within 24 hours of
sildenafil or vardenafil administration or within 48 hours of
tadalafil administration

Webb DJ et al. Am J Cardiol. 1999;83: 21C–28C.

Kloner RA et al. J Am Coll Cardiol. 2003;42:1855–1860
18
19
Role of PDE 5 inhibitor

• Sildenafil ,Vardenafil, Tadalafil

• No studies have shown one agent to be more effective or safer than
the others.
• Despite occasional anecdotal case reports linking PDE5 inhibitors to
cardiac events, large trials and meta-analyses suggest that they are
not associated with an increase in MI or cardiac events.

Kloner RA, et al. Am J Hypertens. 2001;14:70–73. 94.

Kloner RA, et al. Am J Cardiol. 2003; 92:47M–57M.
Cheitlin MD, et al.Circulation. 1999; 99:168–177
Mittleman MA, et al. Am J Cardiol. 2005;96:443–446. 20
Drug for Sexual Dysfunction
Recommendation?

Sildenafil
■ In healthy volunteers, sildenafil produced a modest decrease in blood
preassure
-------------------- 8,4 mmHg systolic
-------------------- 5,5 mmHg diastolic
■ In patient receiving medication containing nitrates, hypotensive effect of
sildenafil can be severe
■ Absolutely contraindicated in patient receiving long acting nitrates, but in
patient who taking short acting nitrates sildenafil can be given within 24
hours after last dose of short acting nitrates.

Kloner RA, et al. Am J Hypertens. 2001;14:70–73. 94.

Kloner RA, et al. Am J Cardiol. 2003; 92:47M–57M.
Cheitlin MD, et al.Circulation. 1999; 99:168–177 Levine et al, 2012
Mittleman MA, et al. Am J Cardiol. 2005;96:443–446. 21
Drug for Sexual Dysfunction
Recommendation?

Sildenafil
■ Sildenafil avoid in :
1. MI, stroke, or life threatening arrhymia in last 6 months
2. Resting BP <90/50 mmHg or >170/110 mmHg
3. Active cardiac failure or unstable angina
4. Complicated multi-drug antihypertensive regimen
5. Rhinitis pigmentosa

Kloner RA, et al. Am J Hypertens. 2001;14:70–73. 94.

Kloner RA, et al. Am J Cardiol. 2003; 92:47M–57M.
Cheitlin MD, et al.Circulation. 1999; 99:168–177 Levine et al, 2012
Mittleman MA, et al. Am J Cardiol. 2005;96:443–446. 22
Drug for Sexual Dysfunction
Recommendation?

Vardenafil
■ 2.5-20 mg better with empty stomach
■ Onset 15-30 min, half life 4-5 hrs
■ Should NOT be used in congenital long QT syndrome or those
taking quinidine, procainamide, amiodarone or sotalol
■ Worsen the hypotensive effect of adrenergic receptor blocker
such as doxazosin and terazosin

Kloner RA, et al. Am J Hypertens. 2001;14:70–73. 94.

Kloner RA, et al. Am J Cardiol. 2003; 92:47M–57M.
Cheitlin MD, et al.Circulation. 1999; 99:168–177 Levine et al, 2012
Mittleman MA, et al. Am J Cardiol. 2005;96:443–446. 23
Drug for Sexual Dysfunction
Recommendation?

Tadalafil
■ 10-20 mg
■ Longer duration of action 36 hours
■ Can be taken with food
■ Back pain or myalgia 6 %
■ Avoid alfa adrenergik blocker severe hypotension

Kloner RA, et al. Am J Hypertens. 2001;14:70–73. 94.

Kloner RA, et al. Am J Cardiol. 2003; 92:47M–57M.
Cheitlin MD, et al.Circulation. 1999; 99:168–177 Levine et al, 2012
Mittleman MA, et al. Am J Cardiol. 2005;96:443–446. 24
Drug Related Sexual Dysfunction

25
26
Herbal Medicine

• Numerous herbal medications are advertised to patients for the

treatment of sexual dysfunction.
• Some of these medications may contain drugs, such as PDE5
inhibitors (or chemically similar substances), yohimbine, or L-
arginine.
• Such drugs can interact with cardiovascular medications, have
vasoactive or sympathomimetic properties, can elevate or reduce
systemic blood pressure, or have been associated with adverse
outcome in patients with CAD.
• Therefore, it may be reasonable to caution patients with CVD about
the use of herbal medications with unknown ingredients advertised
for the treatment of sexual dysfunction.

Savaliya AA, et al.J Pharm Biomed Anal. 2010;52:406–409. 118.

Oh SS, et al. J Toxicol Environ Health A. 2006;69:1951–1958. 119.
Kearney T, et al. Ann Pharmacother. 2010;44: 1022–1029. 27
Take Home Massage

• Sexual activity is predictor of QoL in Heart Disease patient

• Reaching 4 Mets means Relatively Safe for Sex
• Trust in Sexual Partner is Important
• Using Drug to achieve Sex’s Satisfaction is not a Sin
• Let’s Having Sex as long as in Stable Condition

28
Now I Can Play Safe Sex ,
without worrying about
Heart Attack
anymore.....Yeaayy !!

29