This presentation describes cardiovascular risk of sexual activity as well as recommendation to manage erectile dysfunction in men with coronary artery disease

1. Sexual Activity After
Myocardial Infarction
Tarek Anis, M.D.
Prof. of Andrology, Cairo University

2. Cardiovascular Aspects of Sexual
Medicine
The 3rd International
Consultation on Sexual
Medicine, Paris 2010
Graham Jackson
Piero Montorsi
Tarek Anis
Michael A Adams
Ahmed El-Sakka
Martin Miner
Charalambos Vlachopoulos
Edward Kim

4. Cardiovascular Disease
Statistics in the Middle East

5. Cardiovascular Disease Statistics
in the Middle East
World Health Organization estimates that 17.5 million people
around the globe die of CVDs each year, representing 30%
of all deaths world wide.
CVDs are no longer diseases of the developed world. About
80% of CVD deaths took place in low- and middle-income
countries. CVDs are the leading cause of death in those
countries.
At least 20 million people survive heart attacks every year.
For those patients and their partners, sexual activity is an
important component of life.
World Health Organization (WHO) estimates, in 2006

6. Cardiovascular Disease Statistics
in the Middle East
The World Health Organization estimates indicate that there is a
marked increase of cardiovascular deaths in most countries from the
Middle East region compared with data from western countries,
particularly from ischemic heart disease and hypertensive heart
disease
The median age at presentation with myocardial infarction is
51 years in the Middle East; this is lower than the median
age at presentation in nine other regions, and is 12 years
lower than the median age at presentation in Western
Europe
Yusuf S, Hawken S, Ounpuu S, et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries
(the INTERHEART study): case-control study. Lancet. 2004;364: 937–952.

7. Current Death Rates from Cardiovascular
Disease in the Middle East
Deaths per 100,000
World Health Organization. Data and statistics: mortality and health status. Available from: http://
www.who.int/research/en/. Accessed January 12, 2012

8. Knowing that the projected increase in
coronary deaths between 1990 and
2020 in the established market
economies is 46%, what do you think it
would be in the Middle East ?
1) About the same
2) 92 % (2 times)
3) 138 % (3 times)
4) 171 % (almost 4 times)

9. Projected Increase in Coronary
Deaths between 1990 and 2020
200
171%
150 144% 144%
% increase
127%
108%
100
50 46%
0
Middle America India China sub- Latin
East & Europe Saharan America
Africa
Okrainec K, Banerjee DK, Eisenberg MJ. Coronary artery disease in
the developing world. Am Heart J. 2004;148:7–15.

10. Prevalence of Diabetes
Source : International Diabetes Federation

11. Prevalence of Diabetes
6 of the top 10 countries
19.5%
20 16.7%
15.2%
14.4%
15 13.1%
11%
10
5
0
U.A.E Saudi Arabia Bahrain Kuwait Oman Egypt

12. Trends in Total Cigarette Consumption
in Eastern Mediterranean and Americas
Guindon DE, Boisclair G. World Health Organization Tobacco Free Initiative. Past, Current and Future
Trends in Tobacco use. HNP discussion paper series; economics of tobacco control paper no. 6 (2003).
Available from: http://siteresources.worldbank.org/H

13. Prevalence of Obesity
Source : International Diabetes Federation

14. The Relation between
Erectile Dysfunction and
Cardiovascular Diseases

15. The Prevalence of ED
ED is a remarkably 80 77.6
common condition.
60.2
60
43.7
40
23.9
ED in a substantial 20
6.5 3.8
8.2
majority of men is 0
20-29 30-39 40-49 50-59 60-69 70-74 >75
due to underlying n=2536, ED 18.5 %
vascular causes. Associations Between ED
and Various Comorbid States
100%
ED is highly
90%
80%
70%
prevalent in men
60%
50%
40% 49% 52%
30%
35%
with vascular risk 20%
10%
0%
24%
15%
factors for CVD.
Diabetes mellitus Obesity Heart disease Hypertension Smoking
Christopher S Saigal, Hunter Wessells, Jennifer Pace, Matt
Schonlau, Timothy J Wilt. Predictors and prevalence of
erectile dysfunction in a racially diverse population. Arch
Intern Med. 2006;166:207-212

16. Risk Factors of ED
Traditional Underlying Emerging
Age Obesity insulin resistance/
High LDL cholesterol Sedentary lifestyle metabolic syndrome
Low HDL cholesterol Atherogenic diet
Hypertension
Diabetes
Smoking 1 2 3

17. Traditional Underlying Emerging
Age Obesity insulin resistance/
High LDL cholesterol Sedentary lifestyle metabolic syndrome
Low HDL cholesterol Atherogenic diet
Hypertension
Diabetes
Smoking 1 2 3

18. Risk Factors of CVDs
Traditional Underlying Emerging
Age Obesity insulin resistance/
High LDL cholesterol Sedentary lifestyle metabolic syndrome
Low HDL cholesterol Atherogenic diet
Hypertension
Diabetes
Smoking 1 2 3

19. ED is an Indicator for Increased Risk
of Coronary Artery Disease
Anton Ponholzera, Christian Temmlb, Rudolf Obermayrc, Clemens Wehrbergera, Stephan Madersbacher. Is Erectile Dysfunction
an Indicator for Increased Risk of Coronary Heart Disease and Stroke?. European Urology 48 (2005) 512–518

20. Degree of ED Related to Extent
of Coronary Artery Disease
Sexual activity in the previous month in with ischemic
heart disease
Frequency of any 1.2
erection* 2-3 vessles
2.1
Single vessle
No of erections 1.2
sufficient for 2.7
penetration
1.8
Difficulty achieving
erection# 3
0 1 2 3 4
* 0 = not at all, 4 = always
# 0 = extreme difficulty (i.e. no erections), 4 = no difficulty
Greenstein A., et al. Int J Impot Res, 1997:9123-126

21. Erectile dysfunction a marker of
coronary artery disease
1) This is specially true for older patients
(above 60)
2) This is specially true for younger patients
(below 45)
3) Age is irrelevant

22. Incidence of Coronary Artery Disease
with Respect to Age and Erectile
Dysfunction Status
ED No ED
Incidence per 1000 person-years
48.52
29.63
27.15
23.97 23.3
10.72
5.09
0.94
40-45 50-59 60-69 ≥ 70
Age
Inman BA, Sauver JL, Jacobson DJ, McGree ME, Nehra A, Lieber MM, Roger VL, Jacobsen SJ. A population-based,
longitudinal study of erectile dysfunction and future coronary artery disease. Mayo Clin Proc 2009; 84 (2): 108-13.

23. Why We Do not see ED
Patients in Cardiology
Clinics?

24. Cardiovascular Patients self-addressing
ED with their Cardiologist
No of Patients Estimated No with ED Talked about ED
9% 0% 0%
Western Europe Middle East US
Schwarz et al,. A multidisciplinary approach to assess erectile dysfunction in high-risk cardiovascular patients International Journal of
Impotence Research Volume 17, Issue S1 (December 2005)

25. Cardiovascular patients admitting ED with
their cardiologist (physician addressed)
No of Patients Estimated ED Admitted ED Rx for ED
81%
83% 75%
32% 35%
28%
Western Europe Middle East US
Schwarz et al,. A multidisciplinary approach to assess erectile dysfunction in high-risk cardiovascular patients International Journal of
Impotence Research Volume 17, Issue S1 (December 2005)

26. Acute Cardiovascular Effects
of Sexual Activity

27. Energy requirement during sexual
activity to orgasm equals that spent
during
1) Walking at 2 mph
2) Climbing 2 flights of stairs
3) Cycling at 10 mph
4) Walking at 4.2 mph and 16% Grade

28. Energy Requirements (METS) of
Selected Physical Activities
Walking 2 mph, level 2
Walking 3 mph, level 3
Sexual Activity, pre-orgasm 2-3
Sexual Activity, during orgasm 3-4
Climbing 2 flights of stairs 3-4
Cycling 10 mph, level 6-7
Walking 4.2 mph, 16% Grade
13
(Bruce treadmill stage 4)
DeBusk RF. Am J Cardiol. 2000;86(suppl 1):51F-56F.

29. Physiological Responses during
Heterosexual Vaginal Intercourse
During foreplay, systolic and diastolic systemic
blood pressure and heart rate increase mildly
More modest increases during sexual arousal.
The greatest increases occur during the 10 to 15
seconds of orgasm (Heart rate rarely exceeds 130
bpm and systolic blood pressure rarely exceeds 170
mm Hg in normotensive individuals), with a rapid
return to baseline.
Men and women have similar responses
Levine et al., Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation
2012; 125 (8): 1058-72.

30. Acute Cardiovascular Effects of
Sexual Activity
Sexual activity in young healthy married men with his
usual partner is comparable to mild to moderate physical
activity in the range of 3 to 4 METS (≈ of climbing 2 flights
of stairs or walking briskly for a short duration).
This may not characterize all individuals, especially those
who are older, are less physically fit, or have CVD
Some patients, particularly older people, may have
difficulty reaching an orgasm for medical or emotional
reasons and may exert themselves to a greater degree of
exhaustion with relatively greater demand on their
cardiovascular system
Levine et al., Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. Circulation
2012; 125 (8): 1058-72.

31. Sexual Activity and
Cardiovascular Risk

32. Coital Angina
“angina d’amour”
Angina that occurs during the minutes or hours after sexual
activity, represents 5% of all anginal attacks.
It is rare in patients who do not have angina during
strenuous physical exertion and more prevalent in
sedentary individuals with severe CAD who experience
angina with minimal physical activity.
If a patient can achieve an energy expenditure of 3 to 5
METs without demonstrating ischemia during exercise
testing, then the risk for ischemia during sexual activity is
very low.
DeBusk RF. Sexual activity in patients with angina. JAMA. 2003;290: 3129–3132.
Drory Y. Sexual activity and cardiovascular risk. Eur Heart J Suppl. 2002;4(suppl H):H13–H18.

33. Sexual Activity and Myocardial
Infarction
A recent meta-analysis of 4 case-crossover studies, including males
in their 50s and 60s, showed that sexual activity was associated with
a 2.7 increased relative risk of myocardial infarction, compared with
periods of time when the subjects were not engaged in sexual
activity
Dahabreh IJ, Paulus JK. Association of episodic physical and sexual activity with triggering of acute cardiac events:
systematic review and meta-analysis. JAMA. 2011;305:1225–1233.

34. Onset of Myocardial Infarction
Following Sexual Activity
Although sexual activity is associated with an
increased relative risk of cardiovascular events, the
absolute rate of events is very low because exposure
to sexual activity is of short duration and constitutes a
very small percentage of the total time at risk for
myocardial ischemia or MI.
Sexual activity is the cause of 1% of all acute MIs
The absolute risk increase for MI associated with 1
hour of sexual activity per week is estimated to be 2
to 3 per 10 000 person-years
Dahabreh IJ, Paulus JK. Association of episodic physical and sexual activity with triggering of acute cardiac events:
systematic review and meta-analysis. JAMA. 2011;305:1225–1233.
Mulleret al. Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical
exertion. Determinants of Myocardial Infarction Onset Study Investigators. JAMA 1996; 275 (18): 1405-9

35. Onset of MI Following Sexual
Activity
858 patients with prior CAD
Relative risk of MI onset
Time of sexual activity (hours before MI onset)
Mulleret al. Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical
exertion. Determinants of Myocardial Infarction Onset Study Investigators. JAMA 1996; 275 (18): 1405-9

36. Protective Effect of Regular Exercise
The risk of MI onset 2 hours following
3
3
858 patients with prior CHD
2.5
2
sexual activity
2
1.5
1.2 Baseline
1 risk
0.5
0
≤1 2 ≥3
Frequency of physical exertion of ≥ 6 METS
Mulleret al. Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical
exertion. Determinants of Myocardial Infarction Onset Study Investigators. JAMA 1996; 275 (18): 1405-9

37. Sexual Activity and Ventricular
Arrhythmias/Sudden Death
Autopsy studies reported low rates (0.6%–1.7%) of
sudden death related to sexual activity.
82% to 93% were men, and the majority (75%) were
having extramarital sexual activity, in most cases with
a younger partner in an unfamiliar setting and/or after
excessive food and alcohol consumption
The increase in absolute risk of sudden death
associated with 1 hour of additional sexual activity per
week is estimated to be 1 per 10 000 person-years
Levine et al., Sexual activity and cardiovascular disease: a scientific statement from the American Heart
Association. Circulation 2012; 125 (8): 1058-72.

38. Management of ED in
Cardiovascular Patients

39. Cardiovascular Risk Assessment in ED
Patients
Princeton Consensus Panel II
Low Risk Intermediate High Risk
Risk
Asymptomatic; < 3 coronary ≥ 3 major coronary artery
artery disease risk factors, Unstable or refractory angina
disease risk factors,
excluding gender excluding gender Uncontrolled hypertension
Controlled hypertension Moderate, stable angina Left ventricular dysfunction/
Mild, stable angina congestive heart failure
Recent myocardial infarction (NYHA class III or IV)
Has had successful coronary (> 2 < 6 weeks)
revascularization Recent myocardial infarction
Left ventricular dysfunction/ (< 2 weeks), stroke
Uncomplicated past congestive heart failure
myocardial infarction (> 6–8 (NYHA class II) High-risk arrhythmias
weeks)
Non-cardiac sequelae of Hypertrophic obstructive and
Mild valvular disease atherosclerosissuch as other cardiomyopathies
Left ventricular dysfunction/ stroke or peripheral vascular
disease Moderate or severe valvular
congestive heart failure disease
(NYHA class I*)

40. Low risk
Asymptomatic and <3 major risk factors
Controlled hypertension
Mild, stable angina pectoris
Post-revascularization and without residual ischemia
Post-myocardial infarction (MI) (>8 weeks), asymptomatic.
Mild valvular disease
Congestive heart failure (NYHA class I)
The Second Princeton Consensus on Sexual Dysfunction and Cardiac Risk: New Guidelines for Sexual Medicine
Graham Jackson, Raymond C. Rosen, Robert A. Kloner, John B. Kostis, Journal of Sexual Medicine, Volume 3 Page 28 - January 2006

41. Intermediate or Indeterminate
Risk
Asymptomatic and ≥3 CAD risk factors (excluding
gender)
Moderate, stable angina
MI >2 weeks but <6 weeks
Congestive heart failure (NYHA class II)
Non-cardiac atherosclerotic sequelae (peripheral arterial
disease, history of stroke, or transient ischemic attacks)

42. High Risk
Unstable or refractory angina
Uncontrolled hypertension
Congestive heart failure (NYHA class III, IV)
Recent MI (<2 weeks)
High-risk arrhythmias
Moderate to severe valve disease

43. Cardiovascular risk in ED patients
Princeton Consensus Panel II
Sexual
Inquiry

44. Cardiovascular risk in ED patients
Princeton Consensus Panel II
Sexual Clinical
Inquiry Evaluation

45. Cardiovascular risk in ED patients
Princeton Consensus Panel II
Sexual Clinical
Inquiry Evaluation

46. Cardiovascular risk in ED patients
Princeton Consensus Panel II
Sexual Clinical
Inquiry Evaluation
Initiate or resume sexual activity
Low
or treatment for sexual
Risk
dysfunction

47. Cardiovascular risk in ED patients
Princeton Consensus Panel II
Sexual activity deferred until
High
stabilization of
Risk
cardiac condition
Sexual Clinical
Inquiry Evaluation
Initiate or resume sexual activity
Low
or treatment for sexual
Risk
dysfunction

48. Cardiovascular risk in ED patients
Princeton Consensus Panel II
Sexual activity deferred until
High
stabilization of
Risk
cardiac condition
Clinical Cardiovascular
Sexual Indeterminate
Evaluation assessment and
Inquiry Risk re-stratification
Initiate or resume sexual activity
Low
or treatment for sexual
Risk
dysfunction

49. Cardiovascular risk in ED patients
Princeton Consensus Panel II
Sexual activity deferred until
High
stabilization of
Risk
cardiac condition
Clinical Cardiovascular
Sexual Indeterminate
Evaluation assessment and
Inquiry Risk re-stratification
Initiate or resume sexual activity
Low
or treatment for sexual
Risk
dysfunction

50. Sexual Activity and CVD:
General Recommendations
Men and women with stable CAD who have no or minimal
symptoms during routine activities can engage in sexual activity.
This includes patients able to achieve 3 to 5 METS during
exercise stress testing without angina, ischemic ECG changes,
hypotension, cyanosis, arrhythmia, or excessive dyspnea.
In patients with unstable or decompensated heart disease (i.e.,
unstable angina, decompensated heart failure, uncontrolled
arrhythmia, or severe valvular disease), sexual activity should be
deferred until the patient is stabilized.
Levine et al., Sexual activity and cardiovascular disease: a scientific statement from the American Heart
Association. Circulation 2012; 125 (8): 1058-72.

51. According to the American College of
Cardiology guidelines, Resumption of
sexual activity after uncomplicated MI is
allowed after
1) 1-2 weeks
2) 3-4 weeks
3) 6-8 weeks

52. Sexual Activity after Myocardial
Infarction
Before the routine use of reperfusion therapy (thrombolytic therapy or percutaneous
coronary intervention) it was recommended that sexual activity be avoided for 6 to
8 weeks after MI.
In 2005, the Princeton Conference suggested that post -MI patients who had
undergone successful coronary revascularization or had a treadmill test without
ischemia could resume sexual activity 3 to 4 weeks after MI.
The American College of Cardiology guidelines for the management of patients with
ST-elevation Myocardial Infarction allowed sexual activity as early as 1 week after
MI in the stable patient.
Because participation of stable patients in cardiac rehabilitation 1 week after MI has
proved safe, resumption of sexual activity soon after uncomplicated MI seems
reasonable in the stable patients who are asymptomatic with mild to moderate
physical activity (eg, 3–5 METS).
Antman et al, . ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the
American College of Cardiology/American Heart Association Task Force on Practice Guidelines Circulation 2010;121:e441

53. Sexual Activity after Myocardial
Infarction
Exercise training during cardiac rehabilitation increases
maximum exercise capacity and decrease peak coital
heart rate.
Regular exercise is associated with a decreased risk of
sexual activity–triggered myocardial infarction.
Thus, cardiac rehabilitation and regular exercise are
reasonable strategies in patients with stable CAD who
plan to engage in sexual activity.
Muller JE, Mittleman MA, Maclure M, Sherwood JB, Tofler GH; Determinants of Myocardial Infarction Onset Study
Investigators. Triggering myocardial infarction by sexual activity: low absolute risk and prevention by regular
physical exertion. JAMA. 1996; 275: 1405– 1409
Stein RA. The effect of exercise training on heart rate during coitus in the post myocardial infarction patient.
Circulation. 1977; 55: 738– 740.

54. Sexual Activity after Percutaneous
Coronary Intervention (PCI)
The cardiovascular risk of sexual activity after PCI is related to
the adequacy of coronary revascularization.
Patients with complete revascularization should be able to
resume sexual activity within days of PCI, provided there are no
complications related to femoral vascular access.
Patients who undergo PCI via radial access should be able to
resume sexual activity as early as if not earlier than those who
undergo PCI via the femoral access.
In patients with incomplete coronary revascularization, exercise
stress testing may be of benefit in assessing the extent and
severity of residual ischemia.
Levine et al., Sexual activity and cardiovascular disease: a scientific statement from the American Heart
Association. Circulation 2012; 125 (8): 1058-72.

55. Sexual Activity after Coronary
Artery Bypass Graft Surgery
Sexual activity may involve considerable stress on the chest
and breathing patterns, that generate high intrathoracic
pressures, that could compromise sternal wound healing
It is recommended that sexual activity be delayed for 6 to 8
weeks after bypass surgery. Patients should avoid positions
that put stress on the surgical site, and physical vigor is best
reintroduced in a gradual fashion.
Robot-assisted surgery avoids sternum incision; patients
treated with this procedure may be able to resume sexual
activity earlier than those undergoing open surgery
Levine et al., Sexual activity and cardiovascular disease: a scientific statement from the American Heart
Association. Circulation 2012; 125 (8): 1058-72.

56. Cardiovascular Drugs and
Sexual Function

57. Numerous classes of cardiovascular
drugs, particularly β-blockers, are the
cause of ED in Many Coronary artery
disease patients
1) True
2) False

58. Cardiovascular Drugs and ED
Numerous classes of cardiovascular drugs, particularly diuretics and
β-blockers, have been implicated in causing ED; however, recent
studies have not found clear relationships between many
contemporary cardiovascular drugs and ED.
An analysis of 6 studies of 15 000 patients found β-blocker
increased the annual rate of sexual dysfunction by only 5 reports per
1000 patients and the annual rate of ED by only 3 per 1000 patients.
A nocebo effect, in which a patient's knowledge that a drug has been
associated with ED, is an important contributing factor to ED
Cardiovascular drugs that improve symptoms and survival should
not be withheld because of concerns about the potential impact on
sexual function
Ko DT, Hebert PR, Coffey CS, Sedrakyan A, Curtis JP, Krumholz HM. Beta-blocker therapy and symptoms of
depression, fatigue, and sexual dysfunction.JAMA. 2002; 288: 351– 357

59. Efficacy of PDE5 Inhibitors
for Men with Ischemic Heart
Disease

60. Effects of PDE5 Inhibitors on Erection
in Men with Ischemic Heart Disease
Response to Q3 and Q4 of the IIEF
Meta analysis of 9 double-blind placebo-controlled studies
*P < 0.0001 vs placebo Conti CR, et al. Am J Cardiol. 1999;83(5A):29C-34C

61. Effects of PDE5 Inhibitors on Erection
in Men with Ischemic Heart Disease
IIEF-EF score (combined response to Q1-Q5, 15 of the IIEF score)
Meta analysis of 9 double-blind placebo-controlled studies
*P < 0.0001 vs placebo Conti CR, et al. Am J Cardiol. 1999;83(5A):29C-34C

62. Effects of PDE5 Inhibitors on Erection
in Men with Ischemic Heart Disease
Four domains of International Index of Erectile Function
Meta analysis of 9 double-blind placebo-controlled studies
*P < 0.05 vs placebo Conti CR, et al. Am J Cardiol. 1999;83(5A):29C-34C

63. Safety of PDE5 Inhibitors for
Men with Ischemic Heart
Disease

64. PDE5 Inhibitors for Cardiac
Patients
PDE5 inhibitors are generally safe and effective for the
treatment of ED in patients with arterial hypertension, stable
CAD, and compensated heart failure.
No studies have shown one agent to be more effective or
safer than the others.
Despite occasional anecdotal case reports linking PDE5
inhibitors to cardiac events, large trials and meta-analyses
suggest that they are not associated with an increase in MI
or cardiac events.
Kloner RA. Cardiovascular effects of the 3 phosphodiesterase-5 inhibitors approved for the treatment of erectile
dysfunction. Circulation. 2004; 110: 3149–3155
Kloner et al., Cardiovascular safety update of tadalafil: retrospective analysis of data from placebo-controlled and
open-label clinical trials of tadalafil with as needed, three times-per-week or once-a-day dosing. Am J Cardiol.
2006;97: 1778– 1784

65. PDE5 Inhibitors for Cardiac
Patients
The concomitant use of PDE5 inhibitors and α-blocking agents
may result in symptomatic hypotension.Thus, when both are
indicated, the lowest α-blocker dose should be initiated and
tolerated by the patient before the patient begins the lowest
dose of a PDE5 inhibitor.
PDE5 inhibitors should not be administered to treat ED in
patients who are already receiving PDE5 inhibitor therapy for
pulmonary hypertension.
Vardenafil (but not sildenafil or tadalafil) carries a precautionary
statement about prolongation of QT interval and should be
avoided in patients with congenital QT prolongation and in those
taking medications known to prolong the QT interval.
Levine et al. Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association.
Circulation 2012; 125 (8): 1058-72.

66. PDE5 Inhibitors for Cardiac
Patients
Organic nitrates remain an absolute contraindication to PDE5
inhibitor use, because this combination may result in
unpredictable reductions in systemic blood pressure.
Patients with chest pain or acute MI should not be
administered nitrates until at least 24 hours after the last dose
of sildenafil or vardenafil and until 48 hours after the last dose
of tadalafil.
In patients on chronic nitrate therapy who desire to use PDE5
inhibitors, the need for continued nitrate therapy should be
evaluated, particularly in patients who have undergone
complete revascularization.
Cheitlin et al; Technology and Practice Executive Committee. Use of sildenafil (Viagra) in patients with cardiovascular
disease. Circulation. 1999; 99: 168– 177
Kloner et al. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol. 2003;42: 1855– 1860

67. Herbal Medications
Numerous herbal medications are advertised to patients to
treat ED. Some of these medications may contain drugs, such
as PDE5 inhibitors, yohimbine, or L-arginine.
Such drugs may interact with cardiovascular medications, have
vasoactive or sympathomimetic properties, can elevate or
reduce systemic blood pressure, or have been associated with
adverse outcome in patients with CAD.
It may be reasonable to caution patients with CVD about the
use of herbal medications with unknown ingredients.
Savaliya et al. Screening of Indian aphrodisiac ayurvedic/herbal healthcare products for adulteration with sildenafil,
tadalafil and/or vardenafil using LC/PDA and extracted ion LC-MS/TOF. J Pharm Biomed Anal. 2010; 52: 406– 409
Kearney et. Adverse drug events associated with yohimbine-containing products: a retrospective review of the
California Poison Control System reported cases. Ann Pharmacother. 2010; 44: 1022– 1029

68. Patient and Partner
Counseling after
Myocardial In farction

69. Sexual Counseling Following
Acute Myocardial Infarction
Although sexual counseling of patients and partners with CVD
is an important component of recovery, it is rarely provided.
Potential reasons include the lack of experience or comfort
discussing sexual issues, inadequate knowledge regarding
sexual activity and CVD, and limited time
Partners of patients with CVD often have considerable anxiety
about sexual activity, which may adversely impact the sexual
activity of the couple
When information is provided, it is more likely provided in
written form than verbally, more likely to be provided to men
than to women, and rarely provided to the partner
Ivarsson B, Fridlund B, Sjöberg T. Information from health care professionals about sexual function and coexistence
after myocardial infarction: a Swedish national study. Heart Lung. 2009; 38: 330– 335.

70. Sexual Counseling Following
Acute Myocardial Infarction
164 post MI patients
100
80
60
39.6%
40
21.9%
20 14.6%
10.4% 11.5%
6.3%
0
resume
sexual activity
When to
use of NTG for
being well
Warning
signs to
report
rested before
activity
Eating and
drinking before
activity
pain during
activity
Effects of
medications on
sexual activity
Steinke E, Patterson-Midgley P. Sexual counseling following acute myocardial infarction. Clin Nurs Res 1996;
5 (4): 462-72.

71. Sexual Counseling Following
Acute Myocardial Infarction
A discussion about sexual activity is appropriate for men and women
of all ages after MI.
General suggestions to the patient may include being well rested at
the time of sexual activity, avoiding unfamiliar surroundings and
partners to minimize stress during sexual activity, avoiding heavy
meals or alcohol before sexual activity, and using a position that does
not restrict respiration.
The achievement of orgasm may require a greater degree of exertion
and may not be a realistic initial goal in some patients after MI.
Randomized trials have demonstrated that sexual counseling
increased the likelihood of return to sexual activity, improved sexual
desire and satisfaction, and increased confidence and reduced fear of
resuming sexual activity
Froelicher ES, Kee LL, Newton KM, Lindskog B, Livingston M. Return to work, sexual activity, and other activities after
acute myocardial infarction. Heart Lung. 1994; 23: 423– 435

72. Take Home Messages

73. Take Home Message
Countries in the Middle East bear a heavy burden from
cardiovascular disease.
Patients in the Middle East present with myocardial
infarction at a younger age, compared with patients
elsewhere.
The projected future burden of mortality from coronary heart
disease in the Middle East is set to outstrip that observed in
other geographical regions

74. Take Home Message
It is reasonable that patients with CVD wishing to initiate
or resume sexual activity after MI be evaluated with a
thorough medical history and physical examination
Exercise stress testing is reasonable for patients who are
not at low cardiovascular risk or have unknown
cardiovascular risk to assess exercise capacity
Sexual activity is reasonable for patients who can exercise
≥3 to 5 METS without angina, excessive dyspnea,
ischemic ST-segment changes, cyanosis, hypotension, or
arrhythmia

75. Take Home Message
Cardiac rehabilitation and regular exercise can be useful to
reduce the risk of cardiovascular complications with sexual
activity after MI
Sexual activity is reasonable 1 or more weeks after
uncomplicated MI if the patient is without cardiac symptoms
during mild to moderate physical activity
Sexual activity is reasonable for patients who have undergone
complete coronary revascularization and may be resumed (a)
several days after percutaneous coronary intervention if the
vascular access site is without complications or (b) 6 to 8
weeks after standard coronary artery bypass graft surgery,
provided the sternotomy is well healed

76. Take Home Message
Cardiovascular drugs that can improve symptoms and
survival should not be withheld because of concerns
about the potential impact on sexual function
PDE5 inhibitors are effective and safe for the treatment of ED
in patients with stable CAD
It may be reasonable to caution patients with CVD regarding
the potential for adverse events with the use of herbal
medications with unknown ingredients that are taken for
treatment of sexual dysfunction

77. Take Home Message
Anxiety and depression regarding sexual activity should
be assessed in patients with CVD
Patient and spouse/partner counseling by healthcare
providers is useful to assist in resumption of sexual
activity after an acute cardiac event or new CVD
diagnosis
A public awareness education program is needed to
encourage men with ED to seek medical advice early,
where risk factors of CAD are assessed

78. Sexual Activity After
Myocardial Infarction
Tarek Anis, M.D.
Prof. of Andrology, Cairo University