Introduction
Although rare, there is still considerable fear of cardiac arrhythmias and sudden cardiac death (SCD) associated with sexual activity. This fear occurs not only in people with cardiovascular disease, but also in people with no known cardiovascular risk. A recent study published in JAMA examined 6847 SCD over a twenty-six year period in London, with a rare risk of death during sex or within an hour (0.2%). However, the results of this study differed from previous studies due to a lower mean age at risk and a higher proportion of female deaths (1). Although this study was reassuring in terms of event rate, it highlights demographic and phenotypic changes in cardiovascular patients at risk.
In 2012, the American Heart Association (AHA) published a scientific communication on sexual activity and cardiovascular disease (2). In cardiovascular patients, the risk of arrhythmia and SCD varies during sexual activity, yet there has been no update of the AHA guidelines and this topic is rarely discussed in professional guidelines (3,4).
As our non-instrumental and instrumental treatment options for heart disease continue to expand, morbidity and mortality decline, we need to improve patient awareness and education about the impact of our interventions that affect the sexual activity in patients at risk of arrhythmia and SCD.
Sexual activity is a vital component of a patient’s life and has a major impact on overall quality of life. Patients with cardiovascular disease and their partners often have questions about sexual activity. When these questions go unanswered, depression and anxiety can set in, which can indirectly worsen clinical outcomes. Clinicians have a responsibility to provide education about sexuality to patients with various cardiovascular diseases (5-7). Patients and their partners who are not adequately informed may have various concerns about the potential negative effects of sexual intercourse. Fearing that it may aggravate their own or their partner’s disease, they may reduce the frequency of sexual activity or stop it altogether. A survey of 45 patients with heart failure. The majority (77%) have not discussed their sexual concerns with a health professional. Sexual concerns included problems with erection (74%), overprotection of partner (63%), difficulty having an orgasm (51%), lack of sexual interest (42%) and fear of partner feeling unwell during sex (36%) (8).
The issue of arrhythmias and SCD during sex in the patient and his or her partner can be a major challenge for clinicians. Healthcare professionals often feel uncomfortable talking to their patients about sexual activity, especially female patients and members of the LGBTQ community. In a small study, a large proportion of female patients who had suffered a heart attack continued to engage in sexual activity without any guidance from their doctors. When the resumption of sexual activity was discussed with care staff, it was predominantly the patients themselves who initiated the conversation (9).
Pathophysiology of cardiac arrhythmias and sudden death during sex
The arrhythmias induced during sexual activity are due to increased sympathetic activation and/or ischemia (Figure 1). An increase in physical activity leads to an increase in myocardial oxygen demand. Patients with channelopathy and hereditary cardiomyopathies are at increased risk of arrhythmias due to increased sympathetic activity. Patients with ischemic heart disease (IHD) are at increased risk of arrhythmia during physical activity. In individuals with channelopathies, the pathophysiology of how sympathetic activity causes SCD varies. In patients with Brugada Syndrome (BrS), several theories are known regarding the role of the sympathetic nervous system. In these patients, reduced cAMP and norepinephrine concentrations are usually detected in endomyocardial biopsy material with ECG fluctuations, suggesting that cardiac vagal tone is a significant contributor to the cardiac arrhythmia in patients with BrS (10).
Catecholaminergic polymorphic ventricular tachycardia (CPVT) occurs with polymorphic VT due to an inherited dysfunction of calcium ‘handling’ in the sarcoplasmic reticulum of myocardial cells in response to adrenergic stimulation, physical or emotional stressors (11). In contrast, the group of channel abnormalities associated with heterogeneous genetic mutations in long QT syndrome (LQTS) leads to prolongation of cardiac repolarization, QT segment on ECG, which can lead to sudden Torsades de Pointes (TdP) ventricular tachycardia. In patients with LQTS, a wide variety of events can be triggers for TdP. Patients who are at highest risk of SCD during sexual activity tend to have LQT1 and LQT2 phenotypes, and physical activity or emotional stress is a trigger (12). Inherited cardiomyopathies, such as arrhythmogenic right ventricular cardiomyopathy (ARVC) and hypertrophic cardiomyopathy (HCM), may have different degrees of risk beyond phenotypic presentation to SCD, depending on the dominant genetic mutation and disease progression. ARVC is a hereditary cardiomyopathy characterized by fibrotic-fatty infiltration of the right ventricle, but may also affect the left ventricle (13). As this disease progresses, patients are at increased risk of ventricular arrhythmias that can lead to SCD. These ventricular arrhythmias are often triggered by physical exertion and emotional stress. HCM may have a similar clinical presentation in terms of physical activity-induced ventricular arrhythmias and SCD, but this result from cardiomyopathy mutations, with abnormalities in sarcomere proteins causing left ventricular hypertrophy (14).
Lastly, IHD, whether of atherosclerotic origin, coronary artery spasm, myocardial bridging or abnormal coronary artery origin, can all cause acute ischemia when there is an increased metabolic demand on the heart due to physical activity such as sex, often manifesting as angina, chest pain but rarely ventricular fibrillation or polymorphic ventricular tachycardia.
Sexual intercourse – metabolism
Sexual activity requires a low to moderate level of metabolic activity (MET), but even mild physical activity can result in cardiac arrhythmias or SCD in deconditioned patients with cardiovascular disease who attempt orgasm.
When counselling cardiovascular patients, the clinician should confirm that the patient can perform 3-5 METs without complaints before starting sexual activity. This figure comes from a study in which oxygen consumption was measured in 10 healthy volunteers. The study involved married couples aged 25-43 years who engaged in foreplay, intercourse, and orgasm during various sexual activities and positions with coital and non-coital stimulation by their partner or self-stimulation (15). If the clinician is unsure about the patient, a stress test can be performed to assess whether the patient can achieve three to five METs without symptoms or arrhythmias. Although most patients do not experience arrhythmias during sex, in one study 71% of patients experienced arrhythmias similar to those observed during near maximal exercise testing during sexual intercourse (15,16). However, there is a rare risk of lethal or hemodynamically significant arrhythmias, with ventricular extrasystoles being the most common arrhythmias during sexual activity (15,16).
Most patients with cardiovascular disease can safely have sex without risk of clinical arrhythmias or SCD. Even in patients with known, well-controlled supraventricular tachycardia, sexual activity is safe (2). Despite the rare occurrence of cardiac arrhythmias and SCD during sex, some cases have a higher likelihood of arrhythmias or sudden onset of cardiac death during intercourse. This information should be reassuringly communicated to the patient and their partner in a way that improves safety but reduces distress. Demographically, the most likely occurrence of a fatal arrhythmia event is in a middle-aged man with IHD who engages in sexual activity with a younger partner in an extramarital relationship in an unfamiliar setting (17,18). However, it is not only these patients who benefit from counselling about sexual activity. The outcomes and quality of life of congenital heart disease patients are improving. Sexual counselling for patients with channelopathies, non-ischemic structural heart disease and congenital cardiovascular syndromes, especially about the effects of sexual activity on reducing the likelihood of a rare cardiac event, in addition to reassuring these patients about their quality of life and reducing anxiety about having children.
Risk of cardiovascular syndromes during sex
ISCHEMIC HEART DISEASE
Arrhythmias associated with IHD include supraventricular arrhythmias (e.g. atrial fibrillation) and SCD due to ventricular tachycardia and ventricular fibrillation. Although patients with IHD are often advised to safely resume sexual activity to prevent reinfarction and angina, less often is the issue of cardiac arrhythmias and lay cardiopulmonary resuscitation (CPR), primarily for the partner. Although cardiac death during sexual intercourse is rare, there are close witnesses in almost all cases, so it is surprising that survival rates after sex-associated SCD are almost one fifth lower due to the low rate of chest compressions (18). Educating a partner on CPR can not only save the patient’s life, but can reduce fear and anxiety associated with sex and increase the frequency of sexual intercourse. Women’s sexual activity after myocardial infarction showed reduced desire and reduced frequency due to fear of death during sexual activity (19).
NON-ISCHEMIC HEART DISEASE AND INHERITED CARDIOVASCULAR SYNDROMES
Cardiac arrhythmias and SCD may occur in patients with non-ischemic structural heart disease or in structurally normal hearts, such as those with ion channel disease and other inherited cardiovascular syndromes. Non-ischemic structural heart disease such as hypertrophic cardiomyopathy (HCM), arrhythmogenic ventricular cardiomyopathy (AVC), idiopathic fibrosis and aortic dissection have been reported in case reports (20). The risk of death during sex in patients with non-ischemic structural heart disease and their partners may cause anxiety and depression.
In Finocchiaro’s recent study, SCD associated with sex was rare, occurring in 17 of 6847 cases (0.2%), 8 of these patients with non-ischemic cardiac disease (1). Similarly, the Paris-SDEC registry (Paris Sudden Cardiac Death Expertise Center) reported that SCD due to sex was rare (<1%), but non-ischemic structural heart disease accounted for 12.5% of sex-related deaths (18). Overall, non-ischemic cardiac disease has a very low risk of arrhythmia-related death during sex, with safe participation in sexual activity. Patients and their partners should be made aware of the low risk of cardiac arrhythmias and SCD during sex.
LQTS and CPVT are ion channel diseases, which can lead to cardiac arrhythmias such as torsade de pointes (TdP) ventricular tachycardia, or polymorphic ventricular tachycardia (PMVT), which can progress to ventricular fibrillation. Based on an electronic medical review of patients seen by the Genetic Heart Rhythm Clinic, sex-related cardiac events were more likely to be common in CPVT than in LQTS. Sex-induced cardiac events occurred in two of forty-three patients with CPVT (4.7%) but in none of the patients with LQTS (21). Despite a low incidence of sex-induced cardiac arrhythmias or SCD in patients with LQTS, orgasm-induced torsades de pointes VT in patients with type 2 long QT syndrome (LQT2) has been reported in patients with mutations (c.361 del) in the KCNH2 gene (chromosome 7q36) (22). Treatment with beta-blockers may reduce the likelihood of fatal arrhythmias in these patients. Appropriate counselling about the safety profile of sex in patients in cases well controlled with medication can provide reassurance to the patient and their sexual partner.
IMPLANTABLE CARDIOVERTER DEFIBRILLATOR
Implantable cardioverter defibrillator (ICD) devices can be given for primary and secondary prevention indications to our potential patients with life-threatening arrhythmias. It is a life-saving device, yet fear of shock during sexual intercourse can cause significant anxiety and abstinence from sexual activity. Counselling before and after device implantation can reduce anxiety in patients who need an ICD. According to the AHA position statement, sexual activity can be performed as primary prevention in patients with ICDs and as secondary prevention in ICD wearers who are able to complete three to five METs without VT or VF. Sexual activity should be delayed in patients who have had multiple shocks until the underlying cause is stabilized or until antiarrhythmic treatment with a core sedative (23,24).
Optimizing patients to participate in sexual activity after completion of 3-5 METs can be optimally achieved through cardiac rehabilitation can improve sexual function (25). In addition to rehabilitation, targeted ablation by an electrophysiologist can also help patients by improving their physical activity levels. Unfortunately, despite best medical practice, sexual dysfunction can still occur as a progression of the patient’s underlying disease and as a side effect of prescribed cardiovascular medications.
Erectile dysfunction and vaginal dryness can occur as side effects of cardiovascular drugs, often making intimate intercourse difficult, and many patients leave treatment without informing their doctor, leading to uncontrolled arrhythmic events, unwarranted ICD operation and, rarely, SCD. For erectile dysfunction, the use of phosphodiesterase 5 inhibitors is recommended over long-acting nitrate preparations, while vaginal dryness can be effectively treated with topical estrogen preparations (26,27). All these can be complemented by well-chosen couple therapy.
Conclusion
Sex is an essential part of life and reproduction, contributing to overall well-being and quality of life.
In most cases, sex is safe without risk of sudden death or cardiac arrhythmia. However, if life-threatening events occur during infrequent sexual activity, the outcome is often tragic. Patients and their partners should be aware that sex is reasonable and safe in most situations. They should, however, receive personalized advice and education on how to minimize the risk of cardiac arrhythmias or SCD that may accompany their condition, using modern medical ablation treatments. Avoidance of sexual stimulants not approved by the authorities is recommended, and the bystander/partner’s proficiency in lay resuscitation is inevitable. Cardiologists and rehabilitation specialists perform risk assessment of patients at risk of arrhythmias using exercise stress testing and are able to improve outcomes by involving patients in rehabilitation through improved aerobic conditioning.