SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE

C.H.T DR.NEMATIPOUR

C.H.T DR.NEMATIPOUR

SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE IN PATIENTS WITH HEART DISEASE

DR EBRAHIM NEMATIPOUR DR EBRAHIM NEMATIPOUR

CARDIOLOGIST AND PROFESSOR OF TEHRANCARDIOLOGIST AND PROFESSOR OF TEHRAN UNIVERSITY OF MEDICAL SCIENCES UNIVERSITY OF MEDICAL SCIENCES

C.H.T DR.NEMATIPOUR

* Risk of myocardial infarction (MI) after sex

* Sexual activity in patients with heart disease.

* Sexual dysfunction in patients with heart disease

* Treatment of sexual dysfunction in patients with heart disease

SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE

SUBJECTS

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* Sexual function is an important component of quality of life and subjective well- being

* Unfortunately many physicians do not discuss this issue with their patients

* Patients seeking medical attention for sexual dysfunction often have concomitant cardiovascular disease

* Prevalence of erectile dysfunction in CAD patients ranged from 42% to75%

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Pathophysiology of erectile function (1)

Normal sexual function :Normal sexual function :

symphony of simultaneous interplay between psychologic ,

hormonal , vascular , and neurologic factors

Vascular phenomenon


Sexual arousal and erection in men :Sexual arousal and erection in men :

Parasympathetic nerves stimulation , sympathetic pathways activity reduction , release of nitric oxide from endothelium .

( In women result from sympathetic nervous system activation) .

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Smooth muscle relaxation in vascular chambers by

nitric oxide ( NO )

NO stimulate adenylate cyclase intracellular cyclic

guanosine monophosphate ( cGMP ) and cAMP erectile smooth muscle relaxation.

5 cGMP phosphodiestrase revokes vasodilatory effects .

PDE-5 inhibitors prolong the vasodilation PDE-5 inhibitors prolong the vasodilation

Pathophysiology of erectile function (2)


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RISK OF MYOCARDIAL INFARCTION (MI) AFTER SEX

* Maximum relative risk of MI(2.5) is with in 2 hours after sexual activity .

* Absolute increase in risk is small ( contribute to the onset of MI in less than 1 percent of patients )

* Many other trigger of MI ( Psychologic stress , anger , physical activity ) may cause a greater increase in absolute risk because they occur more frequently

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- Mean heart rate : ~ 120 beats per minute - Mean blood pressure : ~ 160/90- 3 to 4 MET (during orgasm ) 1 MET (metabolic equivalent of oxygen consumption ) :

3.5 ml o2 uptake /Kg per min

- Walking at 2 to 4 miles ( ~ 3.2 to 6.4 Km ) per hour on a level Surface - Brisk walk up to two flights of stairs ( ~ 5 MET )

* Modest increase in myocardial oxygen demand that lasts only a brief time


Hemodynamic stress of normal sexual activity

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SEXUAL ACTIVITY IN PATIENTS WITH HEART DISEASE (1)

* Risk assessment befere initiation or resumption of sexual activity :

- Low risk

- Intermediate or indeterminate risk

- High risk


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Low risk patients :

- No symptoms and less than three cardiovascular risk factors ( excluding gender )

- Controlled hypertension

- Mild , stable angina

- Successful coronary revascularization

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- MI more than 6 to 8 weeks previously in asymptomatic patients and no exercise-induced ischemia , or revascularized

- (probably safe 3 to 4 weeks post MI in revasularized and without exercise-induced ischemia )

- Mild valvular disease

* Patients at low risk can be safely encouraged to initiate or resume sexual activity and can be treated for sexual dysfunction

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Intermediate or indeterminate risk patients:

- No symptoms and 3 or more cardiovascular risk factors (excluding gender)

sedentary lifestyle is a risk factor

- Moderate , stable angina

- Recent MI ( more than 2 and less than 6 weeks )

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- Non cardiac manifestations of atherosclerotic disease (peripheral vascular disease or prior stroke or TIA )

* Patients in this group should receive further evaluation , such as stress testing , to restratification into low or high risk category


- Asymptomatic LV dysfunctions ( LVEF < 40% or NYHA class II HF )

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High risk patients :

-Unstable or refractory angina

- Uncontrolled hypertension

- NYHA class III or IV heart failure

-MI within the past 2 Weeks

- High-risk arrhythmia

- Obstructive hypertrophic cardiomyopathy

-Moderate-to-severe valvular disease , particularly aortic stenosis

* Patients at high risk should be stabilized by appropriate therapy and further risk stratified before resuming sexual activity

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SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE (1)SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE (1)

sexual dysfunction is common in patients with cardiovascular disease because of:- Concern about risk- Side effects of medications: -Beta- blockers : ill defined mechanism - Lipid lowering drugs : ( ? ) - Digoxin : sodium-pump inhibition corporeal contraction and impaired NO-induced relaxation . - Spironolacton : androgen suppression ? aplerenone ( more selective )

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-Coexistence of shared risk factors (lipid abnormalities, diabetes, smoking, hypertension)

-presence of psychologic factors

* sexual dysfunction after MI ( most often erectile dysfunction sexual dysfunction after MI ( most often erectile dysfunction inin men) is estimated to occur in one-half to three-quarters ofmen) is estimated to occur in one-half to three-quarters of patients.patients.

SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE (2)SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE (2)


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MODULATION OF RISK AND TREATMENT OF SEXUAL DYSFUNCTION IN PATIENT WITH HEART DISEASE (1)

Factors to modulate the risk of MI after intercourse:

- Exercise : regular exercise , at levels of ≥ 6 METs

(increases aerobic capacity, decreases peack HR) more regular exercise lower relative risk of MI Attendance at cardiac rehabilitation

- Medical therapy: Medication that reduce HR or BP

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MODULATION OF RISK AND TREATMENT OF SEXUAL DYSFUNCTION IN PATIENT WITH HEART DISEASE (2)Treatment of sexual dysfunction:- Correction of reversible causes: * concern about risk: Reassurance in patients in whom sexual activity is safe * drug induced side effects: alternative prescriptions, when possible- Treatment of erectile dysfunction: Phosphodiesterase-5(PDE-5) inhibitors - sildenafil - vardenafil - tadalafil* PDE-5 inhibitors should not be used with nitrates in any form 24 h of sildenafil and vardenafil and 48 h of tadalafil ( even longer in patients with renal or hepatic dysfunction )

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The ACC/AHA consensus statement about the groups of patients at risk of potentially hazardous cardiovascular effects of PDE-5 inhibitors .

- Patients with active coronary ischemia , even who are not taking nitrate ( positive ETT )

- Patients with HF and borderline low BP and /or low volume status .

- patients on a complicated multidrug antihypertensive drugs regimen .

- Patients taking drugs that prolong the half – life of PDE – 5

inhibitors by blocking CYP 3A4


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SUMMERY AND CONCLUSION

- sexual activity is an important component of quality of life and physicians should discuss this issue with their patients- patients seeking medical attention for sexual dysfunction often have concomitant cardiovascular disease- Absolute increase in risk of MI after sex is small and is less than other triggers of MI- Risk assessment of cardiac patients is necessary before resumption of sexual activity- sexual dysfunction is common in patients with heart disease- The important component of treatment of sexual dysfunction is correction of reversible causes- PED-5 inhibitors can improve erectile function in cardiac patients but should never be used concomitantly with any forms of initrates

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SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE