Keep Sex in the Discussion With Coronary Heart Disease Patients
Older patients with coronary heart disease (CHD) are less likely to be sexually active than those without CHD, but a new study suggests that resuming an active sex life puts them back on track with their peers.
Assessing data on 6690 men and women aged 50 and older, UK researchers found that CHD was independently associated with an adjusted 38% reduction in the odds of reporting any sexual activity in men (odds ratio [OR] 0.62, P<0.001) and a nonsignificant decline of 9% in women (OR 0.91, P=0.058).
CHD was also associated with a 46% increase in the odds of men reporting erectile dysfunction (OR 1.46, P=0.009), again after adjustment for age, partnership status, diabetes, and number of comorbidities.
For those looking for the silver lining here, the investigators found no differences among sexually active participants in the frequency of intercourse or other sexual behaviors. Further, concerns about sex between people with and without CHD were small, Dr Andrew Steptoe (University College London, UK) and colleagues report online in Heart.
"This study indicates that the impact of coronary disease on sexual activity is quite limited," Steptoe told heartwire from Medscape. "It"s true that fewer people with heart disease were sexually active, but those who were active did not report any differences in frequency or type of sexual activity or concerns about sexual arousal. So the critical issue is whether the person is sexually active or not."
A surprising two-thirds of men with CHD were sexually active (68.7%), as were around half of women (49.2%). Considering that the sample of men and women with CHD had an average age in the low 70s, "this seems to me to be quite a substantial level of sexual activity," he added.
Time Since Diagnosis
The investigators point out that prior studies have reported lower sexual activity and satisfaction as well as erectile and orgasm difficulties in CHD, but few have investigated sexual behavior in nationally representative samples involving age-matched comparison groups.
To do this, they examined cross-sectional data from 2979 men and 3711 women at least 50 years old from the English Longitudinal Study of Ageing. Of these, 376 men and 279 women had CHD, defined as physician diagnosis of MI (218 men, 111 women) or angina pectoris. Sexual behavior and concerns were assessed by validated self-completed questionnaires, and analyses were weighted for nonresponse.
Participants with CHD were significantly older than those without CHD, less likely to be married or live with a partner, and more likely to have diabetes and more comorbidities.
Not surprising, a more recent CHD diagnosis appeared to cool patients" sexual ardor. Men diagnosed with CHD >4 years had 19% lower odds of being sexually active (adjusted OR 0.81, P=0.099), while those diagnosed <4 years had a 76% decrease in odds compared with men free of CHD (adjusted OR 0.24, P<0.001).
There was no difference between controls and women diagnosed >4 years, but there was a 56% reduction in sexual activity in women more recently diagnosed (adjusted OR 0.44, P=0.013), Steptoe and colleagues report.
The investigators also examined the associations between different classes of cardiac medications and three problematic aspects of sexual activity in CHD: overall sexual activity in both sexes and erectile problems and difficulty achieving orgasm in men.
Only two associations were significant: erectile difficulties were more commonly reported by men prescribed diuretics (adjusted OR 3.70; P=0.012) and statins (adjusted OR 2.03, P=0.048).
Previous studies have reported an association with diuretics, but the statin effect has not been observed before. Steptoe cautioned heartwire , however, not to put much weight on this finding. "We carried out 18 separate statistical tests of sexual activity and medication and so would expect some chance positive associations."
The effect of taking phosphodiesterase type 5 inhibitors such as sildenafil and tadalafil could not be analyzed, because only 5.7% of men with CHD and 7.4% without CHD used this class of drug.
The Sex Talk
Steptoe and colleagues acknowledge there is "a significant but very small risk that sexual activity can trigger acute cardiac events" but suggest that beliefs about such effects "may be magnified in patients and their families unless healthcare staff provide appropriate advice."
They also point out that sexual difficulties are a major source of interpersonal conflict and marital stress and that "these factors are important in CHD, since marital tension and reduced social support may augment risk of recurrent cardiac events."
The investigators conclude that more effective advice about sexual activity may reverse the pattern observed in the study and lead to more satisfying personal lives for CHD patients.
Steptoe said there is a lack of information about sexual activity in patients with heart disease, although the reasons for this are unclear, but that physicians may also be hesitant to raise the topic.
"Squeamishness may be an issue. In addition, physicians are typically much younger than the people we assessed in this study, and they may not think that sex is an important issue for their patients," he said.
"But one thing we have learned from this and other studies of older people is that many men and women continue active sex lives into their 70s, 80s, and beyond and that the importance of sex for the quality of their close relationships should not be ignored."
The ELSA study is funded by the National Institute on Aging and a consortium of UK government departments coordinated by the Economic and Social Research Council. Dr Steptoe is supported by the British Heart Foundation and the coauthors by Cancer Research UK. The authors report no relevant financial relationships.