C.H.TDR.NEMATIPOUR

C.H.T DR.NEMATIPOUR SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE DR EBRAHIM NEMATIPOUR CARDIOLOGIST AND PROFESSOR OF TEHRAN CARDIOLOGIST AND PROFESSOR OF TEHRAN UNIVERSITY OF MEDICAL SCIENCES UNIVERSITY OF MEDICAL SCIENCES

C.H.TDR.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

C.H.TDR.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.TDR.NEMATIPOUR Pathophysiology of erectile function (1) Normal sexual function : symphony of simultaneous interplay between psychologic, hormonal, vascular, and neurologic factors Vascular phenomenon SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE 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.TDR.NEMATIPOUR 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 Pathophysiology of erectile function (2) SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE

C.H.TDR.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.TDR.NEMATIPOUR - Mean heart rate : ~ 120 beats per minute - Mean blood pressure : ~ 160/ to 4 MET (during orgasm ) 1 MET (metabolic equivalent of oxygen consumption ) : 3.5 ml o 2 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 SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE Hemodynamic stress of normal sexual activity

C.H.TDR.NEMATIPOUR 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 SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE

C.H.TDR.NEMATIPOUR SEXUAL ACTIVITY IN PATIENTS WITH HEART DISEASE (2) SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE Low risk patients : - No symptoms and less than three cardiovascular risk factors ( excluding gender ) - Controlled hypertension - Mild, stable angina - Successful coronary revascularization

C.H.TDR.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.TDR.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.TDR.NEMATIPOUR - 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 SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE Asymptomatic LV dysfunctions ( LVEF < 40% or NYHA class II HF ) - Asymptomatic LV dysfunctions ( LVEF < 40% or NYHA class II HF )

C.H.TDR.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.TDR.NEMATIPOUR SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE 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 )

C.H.TDR.NEMATIPOUR -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. * sexual dysfunction after MI ( most often erectile dysfunction in men) is estimated to occur in one-half to three-quarters of patients. SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE (2) SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE

C.H.TDR.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 MET s (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.TDR.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.TDR.NEMATIPOUR 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 SEXUAL ACTIVITY AND SEXUAL DYSFUNCTION IN PATIENTS WITH HEART DISEASE

C.H.TDR.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.TDR.NEMATIPOUR