Sex after chronic heart failure

Although medication can help extend the lives of men with chronic heart failure, several factors associated with this disease can interfere with a person's ability to engage in and enjoy sexual activities.

Fatigue, depression, medication side effects and the fear of damaging the heart can cause people with chronic heart failure to lose interest in sex or wonder whether this activity is safe for them.

A literature review published in the October issue of Mayo Clinic Proceedings finds that with proper screening and treatment, many patients with chronic heart failure can safely engage in sexual activity.

Co-authors Stacy Mandras, M.D., Patricia Uber, Pharm. D., and Mandeep Mehra, M.D., conducted systematic independent literature searches using the MEDLINE database and examined a broad range of medical research that focused on chronic heart failure, sexual activity and sexual dysfunction. This literature included data from patient surveys and clinical trials.

Many people with chronic heart failure worry that having sex will place too great a strain on the heart. To address this issue, Drs. Mandras and Mehra analyzed studies that showed the impact of sexual activity on heart rate, blood pressure and respiratory rates, which typically increase during sexual activity and other forms of exertion.

One study the authors reviewed measured these changes in middle-aged men with and without coronary artery disease. This study found that the peak heart rate during intercourse was lower than heart rates measured during the patients' normal daily activities. The study participants' peak oxygen consumption levels during intercourse were moderate — comparable to their oxygen consumption levels during moderate activities such as walking on level ground at 3 to 4 miles per hour, climbing stairs slowly or doing general housework such as vacuuming.

The authors also addressed how to counsel and treat chronic heart failure patients who are coping with erectile dysfunction, difficulty achieving or maintaining an erection. Researchers estimate that erectile dysfunction affects 60 percent to 70 percent of people who have chronic heart failure.

The authors observe that multiple factors may be involved. In addition to decreased exercise capacity, patients with chronic heart failure have blood vessel and circulation abnormalities that can reduce blood flow into the penis and interfere with the ability to maintain an erection. And erectile dysfunction can be caused or worsened by many of the medications that are commonly prescribed to treat chronic heart failure.

Currently, the preferred treatment for erectile dysfunction includes sildenafil (Viagra), vardenafil (Levitra) and tadalafil (Cialis). However, numerous experts have raised concerns about the use of these drugs in patients with chronic heart failure who also take nitrates (or other medications that relax and widen blood vessels). This drug combination has been shown to be dangerous, because it can increase the risk for a life-threatening drop in blood pressure.

To further explore this potential risk, the authors reviewed results from a variety of studies in which male patients with congestive heart failure took sildenafil. The authors observed that more data are needed to determine the safety of the newer drugs, vardenafil and tadalafil, for these patients.

“Taken together, these studies show that erectile dysfunction in patients with mild to moderate chronic heart failure can be safely and effectively treated with sildenafil, provided that patients are appropriately screened before therapy,” say the authors.

For those patients who cannot take erectile dysfunction medications, the authors counsel that an exercise training regimen may be an appropriate substitute therapy to enhance sexual function and quality of life. The authors stress that clinicians should focus on the sexual activity history of chronic heart failure patients and not ignore it, since addressing this element can substantially improve their quality of life.

Chronic heart failure often develops after other cardiac problems have damaged or weakened the heart, leaving it too weak or too stiff to fill and pump efficiently. Many underlying heart conditions can lead to heart failure. It can develop quickly after damage caused by a heart attack, or it can develop gradually after years of high blood pressure or coronary artery disease.

A peer-review journal, Mayo Clinic Proceedings publishes original articles, reviews and editorials dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 80 years and has a circulation of 130,000 nationally and internationally.