Sex, Stress & Heart Disease

1. Sex, Stress & Heart Disease Cardiology Update Mazankowski Alberta Heart Institute / University of Alberta May 3, 2014 Dr. David E. Johnstone, MD, FRCPC, FACC Zone Clinical Department Head Cardiac Sciences, Edmonton

2. Sex, Stress & Heart Disease Learning Objectives • How stressful is sex in cardiac patients? • When can patients resume sexual activities? • The answer to the question “can I take Viagra?” • Who should not have sex? • Why do we avoid this topic?

3. Cardiac Workshop: Warm-up Questions • Who we are / what do we do? • Discussed sex with a CV patient? • Male / Female • Any previous bad experiences? • Drugs for erectile dysfunction • Complications • Topic covered previously

4. Cardiac Workshop: Guidelines • Interactive • Useful Information • Advice regarding specific patients • Broaden discussion if this topic covered

5. Quality Care 63 year old man presents with chest pain and an inferior STEMI. Urgent cardiac cath revealed an occluded RCA and subcritical LAD & Cx disease. Successful PCI with drug eluting stent • ASA / Plavix / Lipitor • FU • Family Physician • Rehabilitation • Advice • Work, driving, Etc.

6. How Risky is Sex in the CV Patient; Angina • Infrequent (<5%) • Sedentary patients / severe CAD • Other names • Coital angina • Angina d’amour

7. How Risky is Sex; Myocardial Infarction • Infrequent (<1%) • Sedentary patients (3 fold) • Post MI / Unknown CAD, equal risk • 10 vs 20 chances in 1,000,000 per hour

8. How Risky is Sex; Sudden Cardiac Death • Rare (0.6%) • Majority male (85%) • 75% extramarital • Younger partner • Food / Alcohol

9. Cardiac Work & Sexual Intercourse

10. CCS Functional Class of Angina • Ordinary Activity shovel snow sports • Slight Limitation of Ordinary Activity > 2 blocks > 2 flights - sex • Marked Limitation housework < 2 blocks 1 flight 4. Can’t Do Anything < 2 METS

11. Sex; General Recommendations • Exercise > 3 – 5 METS • Rehab – useful • Unstable symptoms (angina / CHF) • No sex

12. 62 year old male with stable angina reports new episodes of angina. What should you do?

13. New Angina During Sex • Give him Viagra • Details needed • Exercise test • Holter / Loop recorder • Send to ER

14. Sex Following MI; Historical Perspective • 6 – 8 weeks (80’s) • 3 – 4 weeks (2005) • 1 week (2012)

15. Sex Post Cardiac Procedures PCI / Stents • Complete vs incomplete revascularization • Femoral vs Radial CV Surgery • 6 – 8 weeks • Sternotomyvs minimally invasive • Emotional time / Rehab helps

16. Heart Failure & Sex • Sexual dysfunction common (85%) • Cessation of sexual activity (25%) • Correlates with functional capacity • Quality of life vs survival

17. Heart Failure & Sex; Recommendations • Reasonable for FC 1 & 2 patients • Not advised for decompensated or FC 3/4 patients • LV function (EF) not helpful

18. Valvular Heart Disease & Sex • No science • Function class important • Stress test helpful

19. Valvular Disease; Sex & Women • Pregnancy may have added dangers • Mechanical valves, anticoagulation and risk to fetus • Inadequate anticoagulation and risk to mom

20. Electrical Heart Disease, Devices & Sex • Atrial fib / flutter • Rate control • Pacemaker / ICDs • Healing phase • ICDs • Heart rate threshold • Fear of discharge

21. 36 year old male, professional with coronary spasm • Asymptomatic • EF 30-35% • Bisoprolol, Perindopril • Several shocks during sex • What caused the shocks? • Was the female partner at risk?

22. Cardiomyopathies & Sex • Hypertrophic CM • Risk of sudden death • Young > Older • Congestive CM • Post-partum CM pregnancy risk • Function class key

23. Cardiovascular Drugs & Sex; Beta Blockers True or False • B-blockers frequently cause erectile dysfunction • B-blockers cause impotence • Nocebo effect is a major contributor

24. Cardiovascular Drug & Sex; Beta Blockers • Sexual dysfunction 5 / 1,000 • Impotence 3 / 1,000 (6 studies, 15,000 patients) • What patients / MDs think important (Nocebo)

25. Cardiovascular Drugs & Sex; Some Facts • Thiazides may contribute to vaginal lubrication issues • Spironolactone causes decrease libido / breasts • ED on thiazide, switch to loop diuretic

26. CV Drugs & Sexual Function; Recommendation • CV drugs that improve symptoms and survival should not be withheld • Dig deeper to exclude other causes • Consider ED therapies in stable patients

27. Drugs for Sexual Dysfunction in the CV Patient • Phosphodiesterase – 5 Inhibitor (PDE5) cause vasodilation • Are effective • Mild reduction in systolic BP • Not associated with MI / cardiac events • Viagra most studied

28. Advice from the audience about experiences with various PDE-5 Inhibitors in CV patients • Any differences? • Any preferences? • Any bad experiences?

29. Vardenafil (Levitra) • Avoid with Class 1 (quinidine) and Class 3 (Amiodarone, Sotalol) • Pharmacokinetics of Levitra NOT influenced by alcohol • Pharmacokinetics of alcohol NOT influenced by Levitra

30. Organic Nitrates & PDE-5 Inhibitors in CV Patients • PDE 5 inhibitors should not be used in patients on NTG • Nitrates should not be administered to patients within 24 hours Viagra and 48 hours for Cialis

31. 48 year old male with prior MI • Successful stenting. Asymptomatic • Travels extensively. EF – 40% • Approved / educated about Viagra and Nitrates • Presyncope and mad as hell ? Why

32. Sildenafil in Heart Failure Patients • Safe in controlled HF despite severe LV dysfunction • Similar BP / pulse changes to other patients Webster LJ, Michilakis ED et al Arch Intern Med 2004; 164;5 14-520

33. Erectile Dysfunction & Cardiovascular Risk • Australian Study (100,000 men) • Severe dysfunction % • Age 45 – 54 2 • Age 55 – 64 7 • Age 65 – 74 20 • Age 75 – 84 50 • 85 & Over 75

34. Erectile Dysfunction & Cardiovascular Risk • Modest increased risk (1.6) in severe ED • Risk marker not risk factor Banks E et al. Pub Med, Jan 29, 2013

35. PDE-5 Inhibitors & Specific Subgroups • Safety unknown in severe AS • Vardenafil carries a warning regarding prolonged QT

36. Psychological Issues to Deal With • Do we discuss? • Who should discuss?

37. Surgical Waitlist