Download sexual activity and sexual dysfunction in patients with heart disease

C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION
IN PATIENTS WITH HEART DISEASE
DR EBRAHIM NEMATIPOUR
CARDIOLOGIST AND PROFESSOR OF TEHRAN
UNIVERSITY OF MEDICAL SCIENCES
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
SUBJECTS
* 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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
* 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%
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
Pathophysiology of erectile function (1)
Normal sexual function :
symphony of simultaneous interplay between psychologic ,
hormonal , vascular , and neurologic factors
Vascular phenomenon
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) .
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
Pathophysiology of erectile function (2)
Smooth muscle relaxation in vascular chambers by
nitric oxide ( NO )
NO stimulate adenylate cyclase
intracellular cyclic
guanosine monophosphate ( cGMP ) and cAMP
smooth muscle relaxation.
5 cGMP phosphodiestrase
revokes vasodilatory effects .
PDE-5 inhibitors prolong the vasodilation
C.H.T
erectile
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
Hemodynamic stress of normal sexual activity
- 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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
SEXUAL ACTIVITY IN PATIENTS WITH HEART DISEASE (2)
Low risk patients :
- No symptoms and less than three cardiovascular
risk
factors ( excluding gender )
- Controlled hypertension
- Mild , stable angina
- Successful coronary revascularization
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
- 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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
SEXUAL ACTIVITY IN PATIENTS WITH HEART DISEASE (3)
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 )
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
- Asymptomatic LV dysfunctions ( LVEF < 40%
or
-
NYHA class II HF )
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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
SEXUAL ACTIVITY IN PATIENTS WITH HEART DISEASE (4)
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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
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 )
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE (2)
-Coexistence of shared risk factors (lipid
abnormalities,
diabetes, smoking, hypertension)
-presence of psychologic factors
* sexual dysfunction after MI ( most often erectile
dysfunction in men) is estimated to occur in one-half to
three-quarters of patients.
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
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 )
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
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
C.H.T
DR.NEMATIPOUR
SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE
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
C.H.T
DR.NEMATIPOUR
C.H.T
DR.NEMATIPOUR