Let’s Talk About Sex: How Best to Broach Post-MI Conversations

Sex is no different than other types of physical activity. So why is it so hard for cardiologists to talk about a “return to play”?

Let’s Talk About Sex: How Best to Broach Post-MI Conversations

Claudio Gil Araújo, MD, PhD (CLINIMEX, Rio de Janeiro, Brazil), had some good news for his 63-year-old patient who, just 3 weeks prior, successfully underwent PCI for STEMI.

Sex, with his wife of many years, was back on the table.

During that same visit, though, the patient asked for a follow-up call, in private. Araújo recalled: “He called me and said, ‘I couldn't tell you during the consultation because my wife was right with me. But I have a lover that I’ve had for 2 years. How do I manage that?’” The man was worried that having not just one, but two partners might be too hard on his heart.

Whether mundane or more surprising, sex talk with patients is part of the job, or should be, said Araújo. But it’s not something that all physicians feel equipped to handle, particularly without good tools for assessing important metrics like how often, for how long, and at what level of exertion.

Araújo, on the other hand, has been comfortable talking about post-MI sex for years, most recently at the ESC Preventive Cardiology 2024 meeting. The World Health Organization considers sexual activity as a health metric, he noted. But for many doctors, the topic wasn’t covered in their formal training and remains taboo.

Fully 12 years have passed, for instance, since the American Heart Association (AHA) released its scientific statement on sexual activity and CVD. While a handful of reassuring studies about sex and CVD—mostly of men but also sometimes of women—continue to be published showing limited risks and potential benefits, cardiologists who spoke with TCTMD admitted it’s a topic that both patients and their doctors may find difficult to broach.

It’s a matter of how intense, how frequent, and how long, and when you can start. Because there's a lot of fears about that. Claudio Gil Araújo

Speaking with TCTMD, Glenn N. Levine, MD (Baylor College of Medicine, Houston, TX), lead author of the AHA statement, said it was inspired by the sense that sexual activity “was a topic that probably was underappreciated and not written about, but on everyone’s mind.” The authors did track down a few relevant studies, enough to realize there were sufficient data to pull together a formal statement and get good information out to the community, he added.

When the paper debuted in 2012, “it was massively received,” Levine said. “I did 2 weeks straight of interviews for [news outlets] literally throughout the world.”

Today, disappointingly, sexual activity in the context of CVD still doesn’t get the attention it deserves, he added. “At the end of a 10- or 15-minute busy clinic, this is probably not talked about and not thought about as much as ideal.”

Preventive cardiologist Beth L. Abramson, MD (St. Michael's Hospital, Toronto, Canada), says it behooves physicians to initiate the conversation. “We need to think about the subsequent quality of life for our patients. And this is a very important aspect of a patient's life that sometimes is not discussed, and we need to be prepared to discuss and encourage patients to [do so],” Abramson told TCTMD.

In the context of an MI, cardiologists may be focused on the acute event and subsequent treatments. Short clinic visits leave little time for addressing ways to improve both quantity and quality of life.

“When a patient sees me [after] angioplasty or myocardial infarction, there are over five evidence-based drug interventions that they need to be on, and we need to make sure that they're adherent to it. We get focused on that perspective,” said Abramson. “But [sex] is something we need to open the door [to] for our patients and enable the conversation, because I do think patients want to chat about their quality of life. And they're sometimes fearful and embarrassed about talking about this, even in modern times.”

The value of taking a holistic look that encompasses the patient’s entire life is “something that we just need to be reminded of in our very fast-paced world as cardiologists focusing on data that looks at harder outcomes,” she added.

A Lack of Information

Erica Spatz, MD (Yale University School of Medicine, New Haven, CT), co-authored a study in the American Journal of Cardiology, published the same year as the AHA statement, that explored patterns of sexual activity in nearly 2,000 middle-aged adults who’d had an MI. Before they left the hospital, just a third of women and 47% of men reported receiving instructions about resuming sex. Patients who didn’t get that counseling were more apt to report not being sexually active in the year following their event, but whether they had sex had no impact on 1-year mortality.

“Sadly, I think that not much has changed from what we were writing about in 2012,” she commented to TCTMD. This is, in part, Spatz continued, because in general cardiologists think about prognosis and adverse events but “don’t give a lot of anticipatory guidance, meaning what to expect going forward” in terms of day-to-day life with cardiovascular disease.

They're sometimes fearful and embarrassed about talking about this, even in modern times. Beth L. Abramson

After a life-threatening event, like a heart attack, “I think we do a poor job about giving people information about their physical, psychological, and sexual health and how to think about that as people are recovering,” she said, noting that the same applies in chronic cardiovascular diseases like heart failure.

Overall, “we're pretty muted about it clinically and we're not seeing a lot of research or papers, so it's not being . . . put on our radar,” Spatz said.

That often leaves patients seeking answers online, where the AHA and other consumer health websites may—or may not—offer helpful information. But without knowing how to tailor any generic advice to their own specific circumstances, many MI survivors may be putting themselves at risk or forgoing activities important to their quality of life.

A Walk, a Jog, or a Sprint?

The 2012 AHA statement specifies that patients with a prior MI who are asymptomatic, have no ischemia on stress testing, or have had complete revascularization are at low risk for experiencing another MI during sex. “Because participation of stable patients in cardiac rehabilitation exercise programs 1 week after MI has proved safe, resumption of sexual activity soon after uncomplicated MI seems reasonable in the stable patient who is asymptomatic with mild-to-moderate physical activity (eg, 3-5 METs [metabolic equivalents]),” the document says. After an uncomplicated PCI, as well, patients can return to sex within days.

Levine tried to put that in context for TCTMD. “If you can get up to 3 or 5 METs, if you can walk up two flights of stairs, generally, you can do sexual activity,” he said.

Abramson, likewise, pointed out that 3-5 METs is equivalent to the second stage of the Bruce protocol for stress testing. Thus, being ready for sex requires being able to do “moderate activity,” which is more intense than leisurely activity but “doesn't have to be vigorous activity” along the lines of downhill skiing or a game of squash.

With CABG, the answer is slightly more complex. “Because 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 generally recommended that sexual activity be delayed for 6 to 8 weeks after CABG and noncoronary open heart procedures,” the AHA statement specifies. “Patients who have undergone surgery should be counseled to avoid positions that cause discomfort or put undue stress on the surgical site, particularly in the early postoperative months. Physical vigor in such patients is best reintroduced in a gradual fashion,” though most people can get back to having sex after CABG.

If you can get up to 3 or 5 METs, if you can walk up two flights of stairs, generally, you can do sexual activity. Glenn N. Levine

Understanding “vigor,” however, introduces more layers to an already difficult conversation. Not only are patients reluctant to ask about sex—and doctors squeamish to bring it up—sexual activities, just like physical ones, entail different levels of cardiovascular fitness, and frequency matters. Those, too, need to be discussed.

To that end, Araújo and colleagues came up with an acronym, KiTOMI, which stands for kissing, touching, oral sex, masturbation, and intercourse. Rather than only gauge sexual activity’s impact by heart rate or METs, “let's try to put this into the more contextualized model,” he said.

With that context, “I can easily now stratify the risk,” Araújo explained. “It’s a matter of how intense, how frequent, and how long, and when you can start. Because there's a lot of fears about that—especially the patient that never had a symptom [and then] got a heart attack.”

Patients’ partners also are often scared to return to sex, he added. “I even saw one paper from the US telling [them] you may have an automatic defibrillator at home. So can you put this below the pillow? It'll be very, very low sex appeal to have a defibrillator under the pillow, you know? So I think we should put this in a perspective.”

Per KiTOMI, Araújo said there’s “no problem” if patients start kissing and touching in the first 24 hours after an MI, for example, and after several more days have passed, no reason why a woman couldn’t use a sex toy if she feels well.

He frames the concept as a “return to play,” a phrase commonly used with athletes who’ve experienced a health-related obstacle. For athletes, the advice is: “You're not going to compete in the Olympics 1 day after you had a knee surgery, but you will [eventually get] there. Just take your time.”

Araújo has a similar message for MI patients: “You are not pursuing a personal record in the next week of sexual performance. Go slow, get confident. If you feel something [unusual], okay, we will take care of it.”

Clinicians also should be aware that some medications taken after MI can impact sexual performance, though there’s no reason to worry patients ahead of time; Araújo urged taking a wait-and-see approach to those side effects. Addressing this, the 2012 AHA statement advises not withholding CV drugs that can improve symptoms and survival out of worries that they’ll impact sexual function. The paper also offers guidance on how to safely prescribe drugs aimed at addressing erectile dysfunction.

Finding the Right Words

Finding the right words to kick off the sex talk can be hard, all of the cardiologists who spoke with TCTMD acknowledged.

Heading into the conversations, clinicians can be assured that sex, for most, is safe. “Post-myocardial infarction, after angioplasty, we are in an era of where our patients are usually not having symptoms of coronary artery disease,” said Abramson. “So I think the conversation should be had about how are they feeling right now [not only] from a physical but a mental health perspective as well.”

A simple question—How is intimacy?—can be a good stand-in for direct questioning about sex, she suggested.

And while physical safety is one thing, there’s also a need to think about the emotional aspect. “If someone has been through a serious life-threatening event, they may want to have a pause and a reevaluation of just what they're doing with their life . . . and reengage in their relationships,” she said. “Sexual activity is one aspect of that, but intimacy comes in all sorts of ways, and I tell my patients who actually are sicker, who may have congestive heart failure, who may not be well enough [for much activity], that there are all sorts of types of intimacy.”

I realized that the onus was on me to bring this up, not the patient, and that not talking about it doesn't mean that it's not on the patient's mind. Erica Spatz

Spatz said her impression is that doctors are more comfortable addressing medical concerns, like erectile dysfunction, that can be alleviated with treatment than they are with the broader concept of sexual health. It may help to realize, she said, that “the patient is more likely to feel 10 times as awkward as a clinician—somebody who is trained and [already] thinks about the body and functions.”

Through her own research, “I realized that the onus was on me to bring this up, not the patient, and that not talking about it doesn't mean that it's not on the patient's mind,” Spatz added. “I try to normalize it.”

The first step can be simple, Araújo agreed. “Ask the right question and be good listeners.” In the beginning, he starts with the broad query: “What about your sexual life?” The answer, he said, is often a brief: “Yes, it’s good.”

Most people want to have the freedom to ask their doctor about sexuality but don’t know how to do so. This is especially true for men, said Araújo, who during adulthood may have had fewer clinical encounters than women and need more time to ask hard questions. “I take a slow deep breath allowing maybe a pause of 10 or 15 seconds,” he said. With this window, some patients get up the courage to speak about any problems they’re having, including erectile dysfunction and their interest in medication to address it.

KiTOMI can serve as a reminder in these conversations that intercourse may not be the end goal for everyone and is not the only type of sexual activity, with the details depending on things like a person’s sexual orientation/gender or cultural background. Age, though, isn’t a barrier. “I ask the same question for people 80 years old,” Araújo said.

Abramson, stressing that CVD is a disease not exclusive to older men, agreed that “it is absolutely important to ask all of our patients, male and female, or whatever [gender] they identify with, about intimacy. . . . Asking the questions in a very professional and appropriate manner and giving patients permission to discuss this is the first step at helping address quality of life.”

None of this should take up much time during the clinic visit. Just 1 or 2 minutes of talking, Araújo said, will make a big difference in a patient’s well-being.

The Other Side of the Pillow

For too long, the unspoken assumption is that sex might be risky, when in fact it could also have unexpected benefits. While it’s no replacement for being otherwise physically active, said Araújo, sex is still a form of exercise and can lead to things like improved flexibility, balance, and strength.

Spatz, when seeing a patient post-MI, discusses the overall trajectory around resuming physical function, a category that she makes a point of telling them includes sex. She also brings up elements of psychological recovery by addressing things like what’s normal to feel and what symptoms merit attention, as well as mental health concerns such as depression.

“Cardiac-wise, people recover pretty quickly. You can go back to work in a week,” Spatz noted. “But psychologically it takes a longer period of time to recover, so I try to put sexual intimacy into that world of recovery.”

She would like to see more research: not on whether sex is safe after MI, but on what’s holding people back from returning to sex. This information could give cardiologists more confidence and data to fall back on. As it is now, “we don't have a script [or an] algorithm for dealing with it, so we don't bring it up,” said Spatz.

Araújo had some advice for colleagues still reticent to discuss this critical topic with their patients: be professional. When he gives lectures on this subject, he often uses the example of the post-MI patient who wanted a private follow-up call to discuss his lover—out of earshot of his wife. Don’t smile or act surprised, he stressed. “This is fundamental. We prepare for [everything from] no sex at all to sex and group sex.” Doctors aren’t there to judge the sex lives of their patients, he said. “Everything is fine.”

Caitlin E. Cox is News Editor of TCTMD and Associate Director, Editorial Content at the Cardiovascular Research Foundation. She produces the…

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