A flood of questions arose following my earlier article on sex and the heart, making it necessary to address unanswered issues related to those with underlying heart disease. While the past focus was on the risk of getting a stroke or a heart attack with sex, my current focus will be on managing sex for those with heart disease.
Heart attack and sex
While data from multiple research trials shows that heart attacks are more likely to occur during sexual activity than at rest, for those who have sex more frequently or who are physically fit, this likelihood is less compared to someone who is desk-bound or a potato couch.
When your doctor tells you that you have significant narrowing of one of your heart arteries, this doesn't spell the end of your sex life. If you are able to walk briskly for 10 minutes without developing chest pain or becoming excessively short of breath, sex with your regular partner will usually not be a problem.
Should the blockage be severe and involve the origin of the left heart arteries (left main artery) or the initial segment of the key artery supplying the main pumping chamber of the heart (proximal left anterior descending artery), a proper discussion with the doctor is necessary as a heart attack involving these arteries is associated with a high risk of sudden death. For these individuals, the risk remains relatively low if chest pain is absent during brisk walking.
Sex after a heart attack
After an uncomplicated heart attack, sexual activity can be resumed if the individual can walk briskly without symptoms. If, however, chest pain or shortness of breath occurs with minimal exertion, sex should be avoided till the heart condition is stabilised. Generally , the risk of death from sex after a heart attack remains small. For those who have suffered a heart attack previously, an hour of physical sexual engagement can increase the risk of a recurrent heart attack or death from 10 chances in 1 million to up to 30 chances in 1 million.
Sudden death during sex
Sudden death during sex
Data from one Japanese and two German published papers showed that sudden death during sexual intercourse (coital death) accounted for 0.6 to 1.7 per cent of all sudden deaths. Coital death occurred predominantly in males (about 80 to 90 per cent were males), mostly during extramarital sex (75 per cent of deaths) with a younger partner away from home, sometimes spiced with liberal alcohol intake.
Surgery for heart disease
Inserting a stent to open a blocked heart artery does not mean that sex is definitely safe. If all the blocked heart arteries have been opened during the procedure, regular sexual activity can be resumed after a week. If there is residual significant blockage of the heart arteries, one can only engage in sex with low risk if a stress treadmill test shows minimal or no abnormal findings.
For those who have undergone heart bypass surgery or open heart surgery for valve disease, once the breast bone surgical wound has healed well and they are able resume routine activities in daily life, sexual activity can resume.
On average, this may take six to eight weeks. However, such individuals will need to adopt positions during sex that will not put undue stress on the surgical wound. A 2007 publication in Heart Lung by Clark reported that those who recovered successfully from heart bypass surgery expressed satisfaction in their sex lives.
Can weak hearts withstand the stress of sex?
No matter how weak the heart pump is, the perennial question "Can I have sex?" always crops up. Those whose hearts are swollen and weakened as a result of a heart attack or viral damage may sometimes develop heart failure with resultant water in the lungs and shortness of breath.
Heart failure patients have decreased appetite, decreased energy and reduced sexual interest. For those who still retain their appetite for sex and are able to do most routine activities of daily living with minimal or no symptoms, sexual activity can continue. If huffing and puffing interferes with the enjoyment of sex, the person will find greater sexual satisfaction by being a passive partner, lying on the back or partially propped up with pillows.
Abnormal heart rhythms
Sex is rarely contra-indicated for those with irregular heart rhythms or those who have a pacemaker or automatic implantable cardiac defibrillator (AICD), as long as they are not impeded in their daily routine as a result of their underlying medical condition. Exceptions may include those with AICD who have received multiple shocks, in which case it is prudent to stabilise the condition prior to resuming regular sexual activity.
Even then, there is no evidence that when the AICD discharges an electrical impulse, the other partner will suffer an electrical shock while in the throes of intimacy.
Overcoming difficulty in enjoying sex
Those with heart conditions may suffer erectile dysfunction to varying degrees and, invariably, the question will pop up "Is it safe for me to take a pill? ". The "pill" refers to phospdodiesterase 5 inhibitors (PDE5 inhibitors), which includes sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis) - all drugs which enhance erectile function.
They are generally safe to use for those with stable heart disease except that Levitra is to be avoided in the case of those with an electrical disorder of the heart called prolonged QT interval. Care must be exercised in certain situations.
As these drugs may cause mild reduction of blood pressure, caution must be exercised when the patient has low blood pressure or is taking alpha-blocking drugs as this may further reduce the blood pressure resulting in symptoms.
The same applies to those who are already on nitrate drugs, where PDE5 inhibitors should be avoided as concomitant use may reduce blood pressure significantly. Therefore, nitrates should be avoided for 24 hours after consumption of Viagra or Levitra, and for 48 hours after consumption of Cialis.
There are two conditions which are associated with reduction in blood flow from the left heart chamber to the aorta, where there is concern about the safety of using PDE5 inhibitors; one is a result of mechanical obstruction caused by thickening of the heart muscle (hypertrophic cardiomyopathy) and the other is severe narrowing of the valve opening into the aorta (severe aortic stenosis). While there is no data on this, there is concern that the use of PDE5 inhibitors may aggravate these medical condition.
Most women who have an underlying heart disease are post-menopausal and the main impediments to sex are vaginal dryness and pain during sex. Topical application of the female hormone, estrogen, in the vagina and at the vulva may relieve these symptoms and have not been demonstrated to increase cardiovascular risk.
Finally, the commonest reason for failure to enjoy sex in those with heart disease is the anxiety of both the patient and the partner concerning the risk of aggravating the underlying heart condition by having sex. Having a good understanding of enjoying sex safely by those with heart disease and their spouses will go a long way in helping them maintain a healthy and intimate sex life.
Dr Lim is medical director at the Singapore Heart, Stroke & Cancer Centre. He is also editor-in-chief, Heart Asia (a journal of the British Medical Journal Publishing Group); chairman, scientific advisory board, Asia Pacific Heart Association; and honorary professor and senior medical adviser, Peking University Heart Centre
This series is brought to you by Heart, Stroke and Cancer Centre. It is produced on alternate Saturdays.