Heart Doctors Urged to Talk about Sex

July 31, 2013

News Review From Harvard Medical School -- Heart Doctors Urged to Talk about Sex

Doctors need to talk about sex with their heart patients. That's the new advice from the American Heart Association and the European Society of Cardiology. For most people, sex is safe even after a heart attack, the statement says. But patients hesitate to bring up the subject. So do doctors, but that needs to change, the statement says. It suggests specific steps for doctors to take after someone has a heart attack, stroke or other serious event. They should check to see if the patient is healthy enough for sex, ordering tests if necessary. Counseling should be geared toward each person's needs. If there's any need for restrictions, doctors should suggest specific positions or how to be intimate without having sex. There are also suggestions for patients. For example, before having sex, make sure you can walk briskly up two flights of stairs without having chest pain or feeling breathless. Tell your doctor about any symptoms. The journal Circulation and the European Heart Journal published the statement. The Associated Press and HealthDay News wrote about it July 30.

By Reena L. Pande, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

Doctors and patients rarely talk about sex. This is especially true after a heart attack. But this may be one of the more important times to have an open conversation about sex. The discussion can include the concerns, the risks and safe practices for patients with heart disease.

The American Heart Association and the European Society of Cardiology released a joint statement about sex and heart disease this week. These groups are urging doctors to bring up the subject of sexual activity with their heart patients. Many people worry about having sex after a heart attack. Most people don't discuss their concerns with their doctors. And most doctors don't ask.

The new guideline urges doctors and patients to speak up and voice their concerns. Here are some of the suggestions for doctors:

• Schedule follow-up visits with patients after a heart attack or related event to make sure they are healthy enough to resume sexual activity.
• Offer counseling that's relevant to each person and his or her medical condition.
• Talk about the specifics of sex. This can include recommended positions for sex, when to resume sex, and other ways to be intimate with a partner.
• If needed, schedule an exercise stress test to make sure it is safe to resume any physical activity, including sex.

What Changes Can I Make Now?

Many people who have had heart attacks are anxious about resuming sexual activity. Their spouses or significant others may also be concerned.

But most people have nothing to be afraid of. Overall, sexual activity is low risk. Many heart-attack survivors can have sex without any major concerns. But ask your doctor to be certain.  

Here are some questions you might ask.

1. Can I ever have sex again?  In most cases, the answer will be yes. But it's worth asking your doctor to make sure he or she agrees.  
2. Am I in good enough shape to have sex after a heart attack?  Most people will be just fine. If you're in good shape and have no symptoms of heart disease, it's probably safe for you to have sex.  On the other hand, if you have chest pain, shortness of breath or other symptoms of heart disease, ask your doctor first. If there are any concerns, your doctor may decide to order more tests (such as a stress test) to decide whether sex is safe for you.
3. Why do I have erectile dysfunction (impotence)? Is there any connection to my heart attack? There are a lot of causes of erectile dysfunction, but some are actually linked to the heart. First, some of the medicines we prescribe after a heart attack, such as beta-blockers, can make sexual problems worse. Depression and other mental health concerns can also be more common after a heart attack, and these can be related to worse sexual function. Finally, some men can get blockages in the blood vessels that lead to the penis. This can cause inadequate blood supply and erectile dysfunction.
4. Can I use Viagra?  Viagra, or similar medicines to treat erectile dysfunction, are largely safe. I do caution my patients that they cannot take these pills and other "nitrate" medicines at the same time. Nitrates, such as nitroglycerin, are given to people with chest pain or other heart conditions. The use of the two types of pills together can lead to a dangerous drop in blood pressure.

Finally, if you are hesitant about talking to your doctor, write down your concerns.  Include them on the list of all the health-related questions you might have, and run through the whole list with your doctor. Just make sure sex is not the last item on your list.

What Can I Expect Looking to the Future?

Let's be honest here. Doctors and patients are both bad at discussing sex. Doctors worry about embarrassing their patients, or they think it's a topic patients would rather not discuss. Patients just wish their doctor would ask so they don't have to bring it up themselves. In the future, I hope that doctors will be increasingly comfortable discussing sex as part of the routine visit after a heart attack.  There is no doubt that this is a big issue for our patients.