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Sexual Activity and Cardiovascular Disease

2012; Lippincott Williams & Wilkins; Volume: 125; Issue: 8 Linguagem: Inglês

10.1161/cir.0b013e3182447787

1524-4539

Glenn N. Levine, Elaine E. Steinke, Faisal G. Bakaeen, Biykem Bozkurt, Melvin D. Cheitlin, Jamie B. Conti, Elyse Foster, Tiny Jaarsma, Robert A. Kloner, Richard A. Lange, Stacy Tessler Lindau, Barry J. Maron, Debra K. Moser, E. Magnus Ohman, Allen D. Seftel, William J. Stewart,

Cardiovascular Issues in Pregnancy

HomeCirculationVol. 125, No. 8Sexual Activity and Cardiovascular Disease Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBSexual Activity and Cardiovascular DiseaseA Scientific Statement From the American Heart Association Glenn N. Levine, MD, FAHA, Elaine E. Steinke, RN, PhD, FAHA, Faisal G. Bakaeen, MD, Biykem Bozkurt, MD, PhD, FAHA, Melvin D. Cheitlin, MD, FAHA, Jamie Beth Conti, MD, Elyse Foster, MD, FAHA, Tiny Jaarsma, RN, PhD, FAHA, Robert A. Kloner, MD, PhD, Richard A. Lange, MD, MBA, FAHA, Stacy Tessler Lindau, MD, Barry J. Maron, MD, Debra K. Moser, DNSc, RN, FAHA, E. Magnus Ohman, MD, Allen D. Seftel, MD and William J. Stewart, MD Glenn N. LevineGlenn N. Levine , Elaine E. SteinkeElaine E. Steinke , Faisal G. BakaeenFaisal G. Bakaeen , Biykem BozkurtBiykem Bozkurt , Melvin D. CheitlinMelvin D. Cheitlin , Jamie Beth ContiJamie Beth Conti , Elyse FosterElyse Foster , Tiny JaarsmaTiny Jaarsma , Robert A. KlonerRobert A. Kloner , Richard A. LangeRichard A. Lange , Stacy Tessler LindauStacy Tessler Lindau , Barry J. MaronBarry J. Maron , Debra K. MoserDebra K. Moser , E. Magnus OhmanE. Magnus Ohman , Allen D. SeftelAllen D. Seftel and William J. StewartWilliam J. Stewart and on behalf of the American Heart Association Council on Clinical Cardiologyand Council on Cardiovascular Nursingand Council on Cardiovascular Surgery and Anesthesia, and Council on Quality of Care and Outcomes Research Originally published19 Jan 2012https://doi.org/10.1161/CIR.0b013e3182447787Circulation. 2012;125:1058–1072Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 IntroductionSexual activity is an important component of patient and partner quality of life for men and women with cardiovascular disease (CVD), including many elderly patients.1 Decreased sexual activity and function are common in patients with CVD and are often interrelated to anxiety and depression.2,3 The intent of this American Heart Association Scientific Statement is to synthesize and summarize data relevant to sexual activity and heart disease in order to provide recommendations and foster physician and other healthcare professional communication with patients about sexual activity. Recommendations in this document are based on published studies, the Princeton Consensus Panel,4,5 the 36th Bethesda Conference,6–10 European Society of Cardiology recommendations on physical activity and sports participation for patients with CVD,11–13 practice guidelines from the American College of Cardiology/American Heart Association14–16 and other organizations,17 and the multidisciplinary expertise of the writing group. The classification of recommendations in this document are based on established ACCF/AHA criteria (Table).Table. Applying Classification of Recommendation and Level of EvidenceTable. Applying Classification of Recommendation and Level of EvidenceA recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.†For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Acute Cardiovascular Effects of Sexual ActivityNumerous studies have examined the cardiovascular and neuroendocrine response to sexual arousal and intercourse, with most assessing male physiological responses during heterosexual vaginal intercourse.18–24 During foreplay, systolic and diastolic systemic arterial blood pressure and heart rate increase mildly, with more modest increases occurring transiently during sexual arousal. The greatest increases occur during the 10 to 15 seconds of orgasm, with a rapid return to baseline systemic blood pressure and heart rate thereafter. Men and women have similar neuroendocrine, blood pressure, and heart rate responses to sexual activity.24,25Studies conducted primarily in young married men showed that sexual activity with a person's usual partner is comparable to mild to moderate physical activity in the range of 3 to 4 metabolic equivalents (METS; ie, the equivalent of climbing 2 flights of stairs or walking briskly26) for a short duration. Heart rate rarely exceeds 130 bpm and systolic blood pressure rarely exceeds 170 mm Hg4,18,27 in normotensive individuals. However, one study of normotensive men demonstrated substantial variations in peak heart rate and systemic blood pressure during orgasm.23 Because most of the studies that assessed the cardiovascular effects of sexual activity were conducted in healthy men who were young to middle-aged, equating the myocardial oxygen demand of intercourse to climbing 2 flights of stairs is a generalization that may not characterize all individuals, especially those who are older, are less physically fit, or have CVD.18 Therefore, it is probably more reasonable to state that sexual activity is equivalent to mild to moderate physical activity in the range of 3 to 5 METS, taking into account the individual's capacity to perform physical activity. Some patients, particularly older people,1 may have difficulty reaching an orgasm for medical or emotional reasons. In attempting to achieve a climax, it is possible that such individuals may exert themselves to a greater degree of exhaustion with relatively greater demand on their cardiovascular system (although specific data on this are lacking).Sexual Activity and Cardiovascular RiskSexual Activity and AnginaCoital angina ("angina d'amour"), angina that occurs during the minutes or hours after sexual activity, represents <5% of all anginal attacks.28 It is rare in patients who do not have angina during strenuous physical exertion and more prevalent in sedentary individuals with severe coronary artery disease (CAD) who experience angina with minimal physical activity. If a patient can achieve an energy expenditure of ≥3 to 5 METs without demonstrating ischemia during exercise testing, then the risk for ischemia during sexual activity is very low.29Sexual Activity and Myocardial InfarctionMeta-analysis of 4 case-crossover studies, which consisted of 50% to 74% males predominantly in their 50s and 60s, showed that sexual activity was associated with a 2.70 increased relative risk of myocardial infarction (MI) compared with periods of time when the subjects were not engaged in sexual activity (Figure).30 The relative risk of MI does not appear to be higher in subjects with a history of MI than in those without prior known CAD.31 Sedentary individuals have a relative risk of coital MI of 3.0, whereas physically active individuals have a relative risk of 1.2.31 The Stockholm Heart Epidemiology Programme (SHEEP) study of post-MI patients (50% women) similarly found that those who were sedentary had a higher risk of MI with sexual activity (relative risk 4.4) than did those who were physically active (relative risk 0.7).32Download figureDownload PowerPointFigure. Forest plot of case-crossover studies assessing the association of sexual activity with myocardial infarction. CI indicates confidence interval. Modified from Dahabreh et al 30 with permission of the publisher. Copyright © 2011, American Medical Association. All rights reserved.30Although sexual activity is associated with an increased risk of cardiovascular events, the absolute rate of events is miniscule because exposure to sexual activity is of short duration and constitutes a very small percentage of the total time at risk for myocardial ischemia or MI. Sexual activity is the cause of <1% of all acute MIs.31 The absolute risk increase for MI associated with 1 hour of sexual activity per week is estimated to be 2 to 3 per 10 000 person-years.30 Individuals with higher habitual sexual activity levels experience smaller increases in risk than individuals with low activity levels. For the individual with a previous MI, the annual risk of reinfarction or death is estimated to be 10% (or as low as 3% if the individual has good exercise tolerance).33 In such individuals, engaging in sexual activity transiently increases the risk of reinfarction or death from 10 chances in 1 million per hour to 20 to 30 chances in 1 million per hour.31Sexual Activity and Ventricular Arrhythmias/Sudden DeathIn an autopsy report of 5559 instances of sudden death, 34 (0.6%) reportedly occurred during sexual intercourse.34 Two other autopsy studies reported similarly low rates (0.6%–1.7%) of sudden death related to sexual activity.35,36 Of the subjects who died during coitus, 82% to 93% were men, and the majority (75%) were having extramarital sexual activity, in most cases with a younger partner in an unfamiliar setting and/or after excessive food and alcohol consumption. The increase in absolute risk of sudden death associated with 1 hour of additional sexual activity per week is estimated to be 21 years of age in the United States. Patients with simple, as well as more complex, disease are at risk for atrial and ventricular arrhythmias, stroke, and rarely coronary ischemia. To date, however, there are only rare reported deaths or strokes during sexual activity in this population. In 1 study, 9% of women with CHD reported symptoms during sexual activity, which included dyspnea, perceived arrhythmia, increased fatigue, or syncope.66 Symptoms were more common in those with severe lesions, worse functional status, or cyanosis. In a survey of men with CHD, 9% reported dyspnea, 9% reported subjective arrhythmias, and 5% reported chest pain with sexual activity, with symptoms more common in patients with greater functional impairment (NYHA class III).67Published guidelines allow for unlimited physical activity in asymptomatic CHD patients with closed or small atrial or ventricular septal defects, mild coarctation of the aorta, closed patent ductus arteriosus, and other mild congenital defects with normal right-sided heart volume, no pulmonary hypertension, and no significant outflow obstruction on the right or left side of the heart.7,11 On the basis of these recommendations, sexual activit