Sexual activity can trigger angina, heart attack, heart failure or sudden cardiac death in patients with CVD.

Few questions on the mind of all patients who had an  recent acute cardiac event or have undergone a cardiac procedure/surgery is ‘ Can I have sex? And when? Is it safe? The answers are not simple and straightforward. But the following is a guide-

1. Acute coronary syndromes — patients who are post  one week from an uncomplicated  heart attack and are asymptomatic with mild to moderate physical activity can safely resume sexual activity.
2. After coronary revascularization —
   Patients can resume sexual activity after –
   1. Three days of uncomplicated angioplasty without vascular access site complications.
   2. eight weeks of uncomplicated bypass surgery if operation site is well healed.
   3. eight weeks of uncomplicated noncoronary cardiac surgery if operation site site is well healed.
3. Heart failure –
   1. New York Heart Association class I or II – are at low risk and can safely participate in sexual activity.
   2. New York Heart Association class III or IV –  are High-risk patients and should have their management optimized prior to engaging in sexual activity.
4. Valvular heart disease-
   1. Aortic stenosis –
      Patients with mild aortic stenosis are generally at low risk.
      Patients with moderate to severe aortic stenosis who are asymptomatic should undergo further risk stratification with exercise stress testing.(Patients with moderate to severe aortic stenosis who are symptomatic are at high risk and should discuss the safety of sexual activity with their cardiologist. )
   2. Other valvular heart disease Patients with the following conditions are at low risk and can safely engage in sexual activity if they are able to tolerate mild to moderate exertion –
      1.   Mild to moderate valvular heart disease and no to mild symptoms (NYHA class I or II)
      2.  Asymptomatic mitral valve prolapse
      3. Normally functioning prosthetic or repaired valves
      4. Successful transcatheter valve intervention.(Patients with severe valvular disease who are asymptomatic should undergo risk stratification with exercise testing.)
5. Arrhythmias, pacemakers, and implantable cardioverter defibrillators —
   Low-risk patients-
   1.  Asymptomatic individuals with pacemakers
   2. Implantable cardioverter defibrillators who have no recent history of multiple shocks.
   3. Patients with paroxysmal atrial fibrillation or flutter, or those with atrial fibrillation or flutter with well-controlled ventricular rates, are also at low risk.

(Patients with atrial fibrillation or flutter and uncontrolled ventricular rates should defer sexual activity until rate control has been.)

Evaluation-

1. The doctors will evaluate your history with emphasis on –
   1. Complete cardiovascular history.
   2. Any symptoms of ischemia, arrhythmia, or heart failure.
   3.  Sexual history,
2. Physical examination-
   To identifying signs of arrhythmia, valvular heart disease, and decompensated heart failure.
3. Risk stratification – should be done for all patients with cardiovascular disease who need treatment for ED. Exercise testing can be used to assess both exercise tolerance and tolerance for sex .
   Patients in low-risk categories can safely be treated for sexual dysfunction.
   Those in high-risk groups require stabilization and optimization of management prior to treatment for sexual dysfunction.

Treatment–

1. Addressing psychologic factors.
2. Organic issues – treat the cause.
3. Assessing for medication related sexual dysfunction-
   Thiazide diuretics and beta blockers can  aggravate ED and should be discontinued but only after consultation with the treating doctor.
4. Cardiovascular risk factor modification – like smoking cessation, weight loss, increased physical activity can improve sexual function.
5. Use of PDE-5 inhibitors in males with CVD —sildenafil is the drug of choice for the treatment of ED in patients with CVD.
   Caution:
   PDE5 inhibitors should be avoided in men taking nitrates or alpha-adrenergic blocker as this combination can cause severe fall in blood pressure.
   1. PDE-5 inhibitors  can be safely combined with other classes of BP medicine.
   2. Patients with
      1. Hypertrophic obstructive cardiomyopathy
      2. Aortic stenosis
      3.  Heart failure should not use PDE- 5 inhibitors.
6. Testosterone – for patients with hypogonadism.
7. Other treatments  options –
   (patients with stable cardiac disease)
   1. penile prostheses
   2. vacuum-assisted erection devices.