Sex advice for people with heart disease

A heart attack often triggers a range of emotions, including sadness, worry, and fear. But after the initial shock wears off, people often just want their lives to get back to normal. Yet amid all the advice about how to recover and protect your heart health going forward, there's one topic that seldom comes up: sex.

"My patients rarely ask questions about sex, and I have to admit that I usually don't bring up the topic either," says Dr. Emily Lau, a cardiologist at Harvard-affiliated Massachusetts General Hospital. However, cardiovascular disease and its treatment can definitely affect sexual function. In addition, certain medications used to treat common sex-related issues may not be safe for people with heart disease.

Heart disease's effect on sex

A buildup of plaque in the arteries (atherosclerosis) is the root cause of most heart attacks. But atherosclerosis can affect arteries throughout the body, including those that supply blood to the genitals. As a result, men may have trouble getting erections, and women may not have the blood flow needed for vaginal arousal and lubrication.

High blood pressure may also contribute to sexual dysfunction by damaging the inner lining of arteries, which contributes to atherosclerosis. Moreover, common blood pressure drugs sometimes lower sex drive or make it more difficult to reach orgasm in both men and women. Of the different classes of drugs for high blood pressure, beta blockers and thiazide diuretics are most likely to cause sexual side effects, says Dr. Lau. Sexual side effects are less likely with ACE inhibitors, angiotensin-receptor blockers, and calcium-channel blockers. (For common examples of blood pressure drugs in these classes, see /tbpmed.)

Medication precautions

For most men with heart disease, drugs to treat erectile dysfunction (ED), including sildenafil (Viagra), tadalafil (Cialis), and vardenafil are safe — with one very important exception. ED drugs shouldn't be used by men who take nitrates, which are most commonly used to treat the chest discomfort known as angina. Because both ED drugs and nitrates work by relaxing and widening blood vessels, taking them together can lead to dangerously low blood pressure.

For women, menopausal symptoms such as hot flashes, night sweats, and vaginal dryness can interfere with a satisfying sex life. "Estrogen products can ease these symptoms, but women who have heart disease should avoid systemic estrogen," says Dr. Lau. Systemic formulations, which include estrogen pills and skin patches, increase the risk of blood clots, she explains. However, estrogen products applied directly to the vagina (creams, suppositories, and rings) can relieve dryness and discomfort during sex and are safe for women with heart disease, says Dr. Lau. "Women can safely use these topical products for as long as they need them," she adds.

Sex after a heart condition

Some couples avoid intimacy after a heart attack because of the fear of having another heart attack during intercourse. But for most people, sex is safe and comparable to other mild- to moderate-intensity activities like brisk walking or climbing up two flights of stairs, says Dr. Lau. If you attend cardiac rehabilitation — ideally starting about a month after your heart attack, as cardiologists strongly recommend — you'll get an exercise stress test. A normal result can provide reassurance for resuming exercise and other activities, including sex, she says. (Also see "Advice for restoring intimacy after a heart attack.")

After any procedure that involves threading a catheter up to your heart through a vessel in your upper thigh, wait until the puncture site has fully healed before resuming sex. After open heart surgery, delay sexual activity until your breastbone has healed, usually six to eight weeks. For several months thereafter, avoid any position that puts stress on your chest.

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