July 29th, 2013
Sex and the Cardiac Patient Should Not be a Taboo Subject
It’s not an easy conversation to have. After a heart attack or other major cardiac event, talking about sex is awkward, and often avoided by patients, their partners, and physicians. But a new consensus statement from several major cardiology organizations urges physicians to get over their reluctance or embarrassment and counsel their cardiac patients about this important, but often neglected, aspect of their lives.
After a patient has a heart attack, stroke, cardiac surgery, cardiac device implantation, or is newly diagnosed with a cardiovascular condition, physicians and other healthcare professionals should provide individually tailored information and advice about a wide variety of issues relating to sexual activity, according to the consensus document developed by the American Heart Association (AHA) and the European Society of Cardiology and published in Circulation and the European Heart Journal. The advice “should address topics such as when to resume sex, specific methods and recommended positions, and the role of intimacy without sex,” said the American Heart Association in a press release.
The statement cites numerous concerns, both psychological and physiological, that patients may have after a coronary event, including “general anxiety, fear of having another MI, feeling unwanted by their partner or not good enough, changes in self-perceptions, inadequate knowledge regarding the impact of heart medications, and finally, partner concerns.”
Most healthcare professionals understand the importance of these issues but do not know what specific advice they should give or when it should be given. They may also be hindered by inexperience and a lack of training, as well as cultural and language barriers. Embarrassment may also play a large role for all the concerned parties. Many heart patients are also elderly, and although sexual activity is by no means absent in this group, it is subject to “stereotypical views on aging and sexuality.” The statement recommends that healthcare providers take a “proactive approach” about sexual concerns and avoid assuming “that sexual issues are of lesser concern to older adults.”
The document addresses many sensitive issues:
Both sexes report fear of intercourse or orgasm after a cardiac event, and often this information is not communicated by the patient to the partner or provider, which leads to stress and possible deterioration of the relationship. Men as partners reported challenges to masculine self-image as a sexual being and hesitancy in approaching their female partners, viewing them as more fragile after MI. Women as partners reported a great sense of loss and uncertainty, both emotional and sexual, related to their male partner with MI.”
The document provides clear advice about assessing risk related to sexual activity. Patients may be relieved to learn that if they do not experience symptoms during an exercise test they are unlikely to experience similar symptoms during sexual activity. Physicians can encourage patients to resume sexual intercourse if they are capable of reaching 3-5 METS on an exercise test:
Sexual activity is often equated with an exercise workload of 2 to 3 METs in the preorgasmic stage and 3 to 4 METs during the orgasmic stage. This is equivalent to walking a treadmill at 3 to 4 miles per hour. This amount of energy expenditure has also been compared to climbing 2 flights of stairs at a brisk pace, although this may not be a useful indicator in those who are older or less physically fit or who have significant CVD. For those with HF, the 6-minute walk test can easily be administered in the clinical setting to assess stability and ability for exertion. HF patients who are not able to manage the 6-minute walk test, or expend ≈3 to 5 METs, may not be able to handle the exertion required for sexual activity. This should be discussed with the patient and partner.”
The documents states that “sexual activity is reasonable” 1 or 2 weeks after an uncomplicated MI if patients do not have symptoms during mild-to-moderate physical activity. Following CABG or other open heart surgery, sexual activity can resume after 6 to 8 weeks.
But, the document notes, “the stress of extramarital sexual activity could pose a health risk for people with heart disease.”
“Patients are anxious and often afraid sex will trigger another cardiac event – but the topic sometimes gets passed over because of embarrassment or discomfort,” said Elaine Steinke, A.P.R.N., Ph.D., lead author of the statement and professor of nursing at Wichita State University in Kansas, in the AHA press release.
“There are many barriers or misconceptions that inhibit discussions about sex. Some healthcare professionals may believe the patient does not want this information, but we have found it is easier for the healthcare provider to start the discussion than for the patient to bring up these issues”, said Tiny Jaarsma, R.N., N.F.E.S.C., co-chair of the task force and a professor at the Linköping University, Sweden, in the press release.