[Sexuality in patients with coronary disease and heart failure]

When a cardiologist is speaking about sexual disorder with a patient with coronary artery disease (CAD) or heart failure (HF) mostly the male sexual disorder is the point. Questions about sexual physical stress and the use of Viagra or MUSE are dominant in the first step. But usually sexual disorders of men and women are a challenge for the cardiologist: is there not another problem behind? Is sexual disorder only a "common symptom"? Is there a need for psychotherapy? There are patients with a "well functioning" of all sexual functions but however feeling unhappy and not satisfied because lacking in sexual fulfilling [32]. The most common questions in my opinion deal with male patients after CABG or valve replacement surgery or after myocardial infarction (MI) or percutaneous transluminal coronary angioplasty (PTCA). Those patients often are concerned about future sexual activity or about a diminished libido. Some fear of failing during intercourse.

The risk of having severe complications during sexual activity is far less than many of the patients and their partners or we the cardiologists would have expected. In only about 0.9% of patients with MI sexual activity was a likely contributor to the onset of MI [27]. Regular exercise reduces the risk of MI by sexual activity. Even in high risk CAD-patients the risk for MI or death are low with 20 chances per million per hour with known CAD [14].

One of the largest and longest during newer studies is the Massachusetts Male Aging Study (MMAS) asking men with an age of 40-69 years. There was a prevalence of ED (3 levels: mild, moderate, complete) of 39% in the 40 years old and of maximal 67% in men with 69 years of age [16]. Common risks for ED are lower education, diabetes, heart disease, hypertension, cigarette smoking, obesity [22]. As early as possible we should reinforce patients (or even "non-yet-patients") to adopt healthy lifestyles with more physical activity to modify risk for sexual malfunction and for heart disease as well [15].

The prevalence seems to be the same as in men. The most common complaints depending upon their age include decreased libido, vaginal dryness, pain with intercourse, decreased genital sensation and difficulty or inability to achieve orgasm [5]. One of the most important problems for older women are the availability of a sexually active partner and the presence of concurrent illnesses. We should ask for sexual history in older women because the need of love and sexual intimacy does not diminish with age [25]. The risks for FSD are age related as well as para-aging: level of education, history of sexual abuse or sexually transmitted disease, the "integrity" of physical health as well as the overall state general happiness [19]. DEPRESSION AS A RISC FACTOR FOR CAD AND IMPAIRMENT OF SEXUALITY: As cardiologists know sexual dysfunction may be a risk indicator for arteriosclerosis and for heart disease or even a consequence of heart disease. Depression is meanwhile recognized as a independent risk factor for MI. But the connexion of depression and sexual dysfunction is a common problem for psychiatrists', gynaecologists', urologists' and cardiologists' consulting-hours [2, 3, 18, 20, 21, 23].

There is very little data available on this topic. Data are dealing with the need of information for patients and partners on the physical stress during sexual activity [33].

The examples for clinical status are given in a simple scheme of the Princeton Consensus Panel. Patients with low risk (the large majority of patients) can be safely encouraged to initiate or resume sexual activity or to receive treatment for sexual dysfunction. In group 2 patients with an intermediate risk should undergo cardiologic evaluation before restratification into low- or high-risk category. In the high-risk patients there is a precondition before resuming sexual activity: stabilisation by specific treatment [13].

Think on the sexual dysfunction when treating female and male cardiologic patients. Work together with other disciplines (gynaecology, psychiatry, sexual medicine, urology) when evaluating a treatment plan. As early as possible try to reinforce lifestyle change for risk factor modification. The absolute risk for death or MI during sexual activity is very low even in patients with known CAD.