Sexual health is a barometer for our overall health , and it’s often viewed as a sign of fitness and strength. It is an important aspect of our happiness in a relationship and our overall success and adaptability in our society . After a cardiac event,return to sexual activity is often not addressed  by physicians and patients are overwhelmed by embarrassment to ask. Not addressing the safety of sex and postponing normal return to sexual activity, may result in guilt,anxiety, depression, and poor cardiac recovery..

The link between the Heart Disease (HD) and Sexual performance

Erectile dysfunction and heart disease share the same pathology and a few common denominators- NO- nitric oxide and endothelial dysfunction, as well as atherosclerotic plaque deposition with narrowing of the arteries. During an erection , penile arteries have to dilate at least 50%; same thing with coronary arteries, during any amount of exercise. 

In other words,  the same risk factors for HD are present in Erectile Dysfunction (ED). – HTN, DM, Metabolic syndrome, Heart disease, High Cholesterol, Smoking.

The presence of Erectile dysfunction should trigger a full cardiac work-up, since most of the time heart disease is present. Atherosclerosis accounts for more than 40% of ED, due to reduced arterial blood flow to penile vessels. Treating the heart disease, does not treat directly the ED; however , treating the risk factors for heart disease, improves the ED .

Low testosterone levels, common in ED, are often present in men with HD. The levels start decreasing normally after 40 years of age.

The sex life may change a bit after a cardiac event, but should be present. Even though we think that our exertion during sex is phenomenal, the amount of calories burned are minimal, and the effort that our heart sustains is similar to walking a full flight of stairs. In medical terms, the ” average coitus” requires the expendure of  about 5 METS- metabolic equivalents; this means passing first stage of an exercise cardiac stress  test, or riding a stationary bicycle, or climbing  brisk a flight of stairs. Heart rate and Blood pressure rose up to 20% during sex, for about 30 seconds only, and then decrease fast to just above baseline.

Since the amount of exertion with sex is small ( compared to what we believe!!), the risk of heart attack in people with coronary disease is 1%, same as in general population. I’m talking about heart attacks, stents, open heart surgery, and not in heart failure, arrhythmias, defibrillators, when the risk may be slightly higher.

After a heart attack, the sexual performance and the libido may be lower, due to  negative side effects of cardiac medications , fear of provoking a new heart attack, decrease heart function-  necessary  to increase the heart rate and blood volume. Depression, which commonly accompanies heart events, also contributes to ED; antidepressant medications are also not ” sex friendly”,having deleterious effects on erectile function and libido (mostly   selective serotonin- reuptake antagonists – zoloft, prozac, paxil, lexapro, )

When is safe to resume sex after a cardiac event 

As per American Heart Association, resuming sex after a cardiac event is safe, as long as there is correction of the underlying disease, and there are no symptoms during daily activities .

• After a heart attack – Generally sex is safe about 3 weeks after a heart attack. I usually recommend a stress test, after the first week, with full completion of the first stage of Bruce protocol ( no chest pain, limiting shortness of breast, arrhythmia) . Passing the stress test gives confidence and reassurance to return to normal sexual performance 

• After Open heart surgery – Any physical activity, including sex is safe 6-8 weeks after, which represents the healing time for the breastbone. Up to 1 year after, avoid positions that put stress on your chest 

• After angioplasty and stenting, without a heart attack – If the procedure was done through your groin, wait 5 days, allowing the puncture site to fully heal.

photo New look feels good photography

Heart Medications with negative impact on Sexual function

• Beta blockers are commonly prescribed after a cardiac event, and would be hard to convince your cardiologist to drop them. The worst offenders are atenolol and propranolol, and the least harmful are metoprolol and carvedilol. Unless heart failure is present, small doses of these medications are prescribed and are unlikely to have a huge impact. No sexual dysfunction is associated with Metoprolol up to 50 mg /day.

• ACEI and ARB, are not commonly associated with ED. They may improve the sexual performance through strengthening the heart and correcting the heart failure . Comon medications of this group are Lisinopril, Benazepril, Ramipril, Valsartan, Losartan.

• Digoxin is a known offender , impairing the sexual function.

• Diuretics, such as HCTZ, are associated with ED

• Spironolactone reduces sexual potency and is associated with breast enlargement

• Statins and Blood thinners are not associated with ED 

Are Erectile Dysfunction (ED) pills safe for the heart?

The three ED pills, PDE-5 inhibitors – Viagra, Cialis and Levitra, are generally safe to use in men with heart disease. A few safety precautions should be taken.

The PDE-5 inhibitors work through nitric oxide pathway, dilating and enlarging the penile arteries, allowing more blood flow to sustain an erection. All arteries in the body contain nitric oxide, responding to these pills by widening  and causing a temporary drop in blood pressure by 5-8 mmHG. This is why they should never be combined to any medication that widens the arteries, such as organic nitrates. Mixing these pills may trigger blood pressure drop by 25-50 mmHG, resulting in syncope.

Nitrates medications, – such as – Imdur, Isordil, and any preparation including Nitroglycerin should be avoided altogether.

FDA warnings about ED pills 

• Avoid if you have active, ongoing symptoms of angina, decompensated heart failure, or uncontrolled blood pressure, > 170/100

• Do not use ED pills if you take nitrates medications

• Reduce dosage if you take medications which can boost the levels of ED pills, such as – Erythromycin, antifungal, anti-HIV pills

• Reduce dosage in men with advanced age, and significant kidney or liver disease.

photo New look feels good photography

Take home points

• Intimacy and sexual activity is safe and beneficial after a cardiac event. 

• Men who suffer from erectile dysfunction often have underlying heart disease. The two different conditions share numerous common risk factors, such as obesity, metabolic syndrome, and low testosterone levels. Presence of ED should trigger cardiac screening for hidden heart disease .

• Lower sexual performance in men with heart disease should not trigger guilt but an active approach of correction of risk factors and proper use of erectile dysfunction medication. 

• Know which cardiac medication may interfere with sexual performance and discuss other options with your physician. Don’t stop cardiac medications since heart performance is mandatory for sexual performance.

• It’s safe to resume sex 3 weeks after a heart attack, 6-8 weeks after open heart surgery, and 5 days after angioplasty and stenting.

• I usually recommend a stress test 1-2 weeks after a heart attack, before resuming sexual life .

• Cardiac rehabilitation after a heart attack and life long exercise are strengthening the heart , improving blood flow, circulation, and thus, sexual performance

• Do not take ED pills if you are using nitrates. 

• Post menopausal women with heart disease may safely use topically or vaginally inserted estrogen for the treatment of painful intercourse