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Canadian Journal of Cardiology

Sexual Activity and Heart Patients: A Contemporary Perspective

Published:October 19, 2015DOI:https://doi.org/10.1016/j.cjca.2015.10.010

      Abstract

      Sexual activity (SA) encompasses several behaviors such as kissing (Ki), touching (T), oral (O) stimulation, masturbation (M), and vaginal/anal intercourse (I). The acronym KiTOMI is proposed here to represent these behaviors. SA, particularly coitus, is a major aspect of health-related quality of life and is often considered the most pleasant and rewarding exercise performed during an entire lifetime. Although several studies have been conducted on sexuality, relatively limited information is available regarding SA in patients with heart disease. Moreover, the level of evidence of this limited information is nearly always B or C. This article provides a comprehensive and updated review of the relevant literature and offers evidence and expert-based practical messages regarding SA in patients with heart disease. Considering the rationale for exercise prescription, SA is typically well tolerated by most clinically stable patients with heart disease. Even in more debilitated and sicker individuals, KiT activities would most likely be feasible and desirable. The absolute risk of major adverse cardiovascular events during SA is typically very low. Even lower death rates have been reported for specific groups, such as women in general, aerobically fit men, and asymptomatic young adults with congenital heart disease. Finally, we emphasize the relevance of sexual counselling for patients and their partners, including the proper use of medications to treat erectile dysfunction. Counselled patients will be reassured and adequately informed regarding how to gradually resume habitual SA after a major cardiac event or procedure, starting with KiT and progressively advancing to KiTOM until all KiTOMI activities are allowed.

      Résumé

      L’activité sexuelle se décline en plusieurs comportements, notamment le fait de s’embrasser (kissing – Ki), de se toucher (T), d’avoir un contact oral (O), de se masturber (M) et d’avoir un rapport vaginal ou anal (intercourse – I). L’acronyme KiTOMI, tiré de la terminologie anglaise, est proposé ici pour représenter l’ensemble de ces comportements. L’activité sexuelle, et plus particulièrement le coït, est un aspect important de la qualité de vie liée à la santé et est souvent citée comme l’activité la plus plaisante et la plus gratifiante de toute une vie. Plusieurs études ont été effectuées sur la sexualité, mais nous ne possédons que très peu d’information sur l’activité sexuelle des patients atteints d’une maladie cardiaque et la qualité de ces données est généralement de niveau B ou C. Cet article vous offre une revue détaillée et à jour de la documentation médicale pertinente, en plus de fournir des preuves factuelles et des suggestions pratiques de la part de spécialistes au sujet de l’activité sexuelle à l’intention des personnes souffrant d’une maladie cardiaque. L’activité physique étant encouragée chez ces patients, l’activité sexuelle est en général bien tolérée par la plupart des patients atteints d’une maladie cardiaque dont l’état est stable sur le plan clinique. En fait, même chez les personnes les plus affaiblies et malades, le fait de se toucher et de s’embrasser est habituellement possible et tout à fait souhaitable. En effet, le risque d’être victime d’un événement indésirable grave de nature cardiovasculaire au cours d’une activité sexuelle est en fait très faible. De plus, le risque de mortalité est plus faible encore chez les femmes en général, les hommes ayant une bonne capacité aérobique et les jeunes adultes atteints d’une cardiopathie congénitale, mais asymptomatiques. L’article met également l’accent sur l’importance, tant pour les patients que pour leurs partenaires, d’être bien conseillés en matière de sexualité, y compris sur la prise adéquate des médicaments destinés à traiter le dysfonctionnement érectile. Il est important que les patients soient informés et rassurés sur la reprise graduelle de leurs activités sexuelles suivant un événement cardiaque grave ou une importante intervention cardiaque. Ils pourront ainsi reprendre tout doucement leurs activités sexuelles en renouant avec le toucher et les baisers, progresser ensuite à la stimulation orale et à la masturbation pour finalement en arriver à la reprise des relations sexuelles complètes.
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      References

        • Smith T.W.
        The JAMA controversy and the meaning of sex.
        Public Opin Q. 1999; 63: 385-400
        • Steinke E.E.
        • Jaarsma T.
        • Barnason S.A.
        • et al.
        Sexual counseling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP).
        Circulation. 2013; 128: 2075-2096
        • Levine G.N.
        • Steinke E.E.
        • Bakaeen F.G.
        • et al.
        Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association.
        Circulation. 2012; 125: 1058-1072
        • Brannstrom M.
        • Kristofferzon M.L.
        • Ivarsson B.
        • et al.
        Sexual knowledge in patients with a myocardial infarction and their partners.
        J Cardiovasc Nurs. 2014; 29: 332-339
        • Lewis R.W.
        • Fugl-Meyer K.S.
        • Corona G.
        • et al.
        Definitions/epidemiology/risk factors for sexual dysfunction.
        J Sex Med. 2010; 7: 1598-1607
        • Sardinha A.
        • Araujo C.G.
        • Nardi A.E.
        Psychiatric disorders and cardiac anxiety in exercising and sedentary coronary artery disease patients: a case-control study.
        Braz J Med Biol Res. 2012; 45: 1320-1326
        • Kazemi-Saleh D.
        • Pishgoo B.
        • Farrokhi F.
        • Fotros A.
        • Assari S.
        Sexual function and psychological status among males and females with ischemic heart disease.
        J Sex Med. 2008; 5: 2330-2337
        • Bispo G.S.
        • de Lima Lopes J.
        • de Barros A.L.
        Cardiovascular changes resulting from sexual activity and sexual dysfunction after myocardial infarction: integrative review.
        J Clin Nurs. 2013; 22: 3522-3531
        • de Araújo C.G.
        Sexual activity: an exercise to prevent cardiovascular morbidity and mortality?.
        Expert Rev Cardiovasc Ther. 2009; 7: 1033-1036
        • Cheng T.O.
        Sexual activity and coronary arterial disease.
        Int J Cardiol. 1990; 26: 387
        • DeBusk R.
        • Drory Y.
        • Goldstein I.
        • et al.
        Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel.
        Am J Cardiol. 2000; 86: 62F-68F
        • Gilon D.
        Sexual activity and coronary artery disease: multiple options.
        Am J Cardiol. 1995; 76: 1321-1322
        • Green A.W.
        Sexual activity and the postmyocardial infarction patient.
        Am Heart J. 1975; 89: 246-252
        • Hellerstein H.K.
        • Friedman E.H.
        Sexual activity and the postcoronary patient.
        Arch Intern Med. 1970; 125: 987-999
        • Kavanagh T.
        • Shephard R.J.
        Sexual activity after myocardial infarction.
        Can Med Assoc J. 1977; 116: 1250-1253
        • Rerkpattanapipat P.
        • Stanek M.S.
        • Kotler M.N.
        Sex and the heart: what is the role of the cardiologist?.
        Eur Heart J. 2001; 22: 201-208
        • Cheitlin M.D.
        Sexual activity and cardiovascular disease.
        Am J Cardiol. 2003; 92: 3M-8M
        • DeBusk R.F.
        Sexual activity triggering myocardial infarction. One less thing to worry about.
        JAMA. 1996; 275: 1447-1448
        • DeBusk R.F.
        Sexual activity in patients with angina.
        JAMA. 2003; 290: 3129-3132
        • Mandras S.A.
        • Uber P.A.
        • Mehra M.R.
        Sexual activity and chronic heart failure.
        Mayo Clin Proc. 2007; 82: 1203-1210
        • Stein R.
        • Hohmann C.B.
        Sexual activity and the heart.
        Arq Bras Cardiol. 2006; 86: 61-67
        • Taylor Jr., H.A.
        Sexual activity and the cardiovascular patient: guidelines.
        Am J Cardiol. 1999; 84: 6N-10N
        • Thorson A.I.
        Sexual activity and the cardiac patient.
        Am J Geriatr Cardiol. 2003; 12: 38-40
        • Carvalho G.M.D.
        • Gonzáles A.I.
        • Sties S.W.
        • et al.
        Exercício físico e sua influência na saúde sexual.
        Cinergis. 2015; 16: 77-81
        • Jackson G.
        • Montorsi P.
        • Adams M.A.
        • et al.
        Cardiovascular aspects of sexual medicine.
        J Sex Med. 2010; 7: 1608-1626
        • Lange R.A.
        • Levine G.N.
        Sexual activity and ischemic heart disease.
        Curr Cardiol Rep. 2014; 16: 445
        • Lunelli R.P.
        • Rabello E.R.
        • Stein R.
        • Goldmeier S.
        • Moraes M.A.
        Sexual activity after myocardial infarction: taboo or lack of knowledge?.
        Arq Bras Cardiol. 2008; 90: 156-159
        • Moons P.
        • Van Deyk K.
        • Marquet K.
        • et al.
        Sexual functioning and congenital heart disease: something to worry about?.
        Int J Cardiol. 2007; 121: 30-35
        • Nascimento E.R.
        • Maia A.C.
        • Pereira V.
        • et al.
        Sexual dysfunction and cardiovascular diseases: a systematic review of prevalence.
        Clinics (Sao Paulo). 2013; 68: 1462-1468
        • Schumann J.
        • Zellweger M.J.
        • Di Valentino M.
        • Piazzalonga S.
        • Hoffmann A.
        Sexual dysfunction before and after cardiac rehabilitation.
        Rehabil Res Pract. 2010; 2010: 823060
        • Steinke E.E.
        Sexual dysfunction common in people with coronary heart disease, but few cardiovascular changes actually occur during sexual activity.
        Evid Based Nurs. 2015; 18: 19
        • Steinke E.E.
        • Jaarsma T.
        Sexual counselling and cardiovascular disease: practical approaches.
        Asian J Androl. 2015; 17: 32-39
        • Chandra A.
        • Mosher W.D.
        • Copen C.
        • Sionean C.
        Sexual behavior, sexual attraction, and sexual identity in the United States: data from the 2006-2008 National Survey of Family Growth.
        Natl Health Stat Report. 2011; 36: 1-36
        • Mulhall J.
        • King R.
        • Glina S.
        • Hvidsten K.
        Importance of and satisfaction with sex among men and women worldwide: results of the global better sex survey.
        J Sex Med. 2008; 5: 788-795
        • Bacon C.G.
        • Mittleman M.A.
        • Kawachi I.
        • et al.
        Sexual function in men older than 50 years of age: results from the health professionals follow-up study.
        Ann Intern Med. 2003; 139: 161-168
        • Laumann E.O.
        • Nicolosi A.
        • Glasser D.B.
        • et al.
        Sexual problems among women and men aged 40-80 y: prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors.
        Int J Impot Res. 2005; 17: 39-57
        • Masters W.H.
        • Johnson V.E.
        Human Sexual Response.
        Little Brown, Boston1966
        • Leiblum S.R.
        After sildenafil: bridging the gap between pharmacologic treatment and satisfying sexual relationships.
        J Clin Psychiatry. 2002; 63 (discussion 23-5): 17-22
        • Levin R.
        • Riley A.
        The physiology of human sexual function.
        Psychiatry. 2007; 6: 90-94
        • Fox C.A.
        • Fox B.
        Blood pressure and respiratory patterns during human coitus.
        J Reprod Fertil. 1969; 19: 405-415
        • Stein R.A.
        Cardiovascular response to sexual activity.
        Am J Cardiol. 2000; 86: 27F-29F
        • Boas E.P.
        • Goldschmidt E.F.
        The Heart Rate.
        Charles C Thomas, Springfield, IL1932
        • Bartlett Jr., R.G.
        Physiologic responses during coitus.
        J Appl Physiol. 1956; 9: 469-472
        • Nemec E.D.
        • Mansfield L.
        • Kennedy J.W.
        Heart rate and blood pressure responses during sexual activity in normal males.
        Am Heart J. 1976; 92: 274-277
        • Palmeri S.T.
        • Kostis J.B.
        • Casazza L.
        • et al.
        Heart rate and blood pressure response in adult men and women during exercise and sexual activity.
        Am J Cardiol. 2007; 100: 1795-1801
        • Souza C.A.
        • Cardoso F.L.
        • Silveira R.A.
        • Wittkopf P.G.
        Heart rate behavior in young adults during physical exercise and sexual activity.
        Rev Bras Med Esporte. 2012; 18: 345-346
        • Xue-Rui T.
        • Ying L.
        • Da-Zhong Y.
        • Xiao-Jun C.
        Changes of blood pressure and heart rate during sexual activity in healthy adults.
        Blood Press Monit. 2008; 13: 211-217
        • Masini V.
        • Romei E.
        • Fiorella A.T.
        Dynamic electrocardiogram in normal subjects during sexual activity.
        G Ital Cardiol. 1980; 10: 1442-1448
        • Littler W.A.
        • Honour A.J.
        • Sleight P.
        Direct arterial pressure, heart rate and electrocardiogram during human coitus.
        J Reprod Fertil. 1974; 40: 321-331
        • Kruger T.
        • Exton M.S.
        • Pawlak C.
        • et al.
        Neuroendocrine and cardiovascular response to sexual arousal and orgasm in men.
        Psychoneuroendocrinology. 1998; 23: 401-411
        • Frappier J.
        • Toupin I.
        • Levy J.J.
        • Aubertin-Leheudre M.
        • Karelis A.D.
        Energy expenditure during sexual activity in young healthy couples.
        PLoS One. 2013; 8: e79342
        • Bohlen J.G.
        • Held J.P.
        • Sanderson M.O.
        • Patterson R.P.
        Heart rate, rate-pressure product, and oxygen uptake during four sexual activities.
        Arch Intern Med. 1984; 144: 1745-1748
        • Araújo C.G.
        • Castro C.L.
        • Franca J.F.
        • Ramos P.S.
        4-Second exercise test: reference values for ages 18–81 years.
        Arq Bras Cardiol. 2015; 104: 366-374
        • Araújo C.G.
        • Vianna L.C.
        How often does spirometry testing induce cardiac arrhythmias?.
        Primary Care Respir J. 2009; 18: 185-188
        • Nóbrega A.C.L.
        • Castro C.L.B.
        • Araújo C.G.S.
        Relative roles of the sympathetic and parasympathetic systems in the 4-s exercise test.
        Braz J Med Biol Res. 1990; 23: 1259-1262
        • Yeragani V.K.
        • Pohl R.
        • Balon R.
        Complex demodulation of cardiac interbeat intervals: increased cardiac sympathovagal interaction during human sexual activity.
        Arch Sex Behav. 2004; 33: 65-69
        • Steinke E.E.
        • Mosack V.
        • Hill T.J.
        Cardiac comorbidities and sexual activity predict sexual self-perception and adjustment.
        Dimens Crit Care Nurs. 2014; 33: 285-292
        • Lindau S.T.
        • Abramsohn E.M.
        • Bueno H.
        • et al.
        Sexual activity and counselling in the first month after acute myocardial infarction among younger adults in the United States and Spain: a prospective, observational study.
        Circulation. 2014; 130: 2302-2309
        • Drory Y.
        • Kravetz S.
        • Weingarten M.
        Comparison of sexual activity of women and men after a first acute myocardial infarction.
        Am J Cardiol. 2000; 85: 1283-1287
        • Tuttle W.
        • Cook Jr., W.L.
        • Fitch E.
        Sexual behavior in postmyocardial infarction patients.
        Am J Cardiol. 1964; 13: 140
        • Shi H.
        • Zhang F.R.
        • Zhu C.X.
        • et al.
        Incidence of changes and predictive factors for sexual function after coronary stenting.
        Andrologia. 2007; 39: 16-21
        • Steinke E.E.
        • Wright D.W.
        • Chung M.L.
        • Moser D.K.
        Sexual self-concept, anxiety, and self-efficacy predict sexual activity in heart failure and healthy elders.
        Heart Lung. 2008; 37: 323-333
        • Mosack V.
        • Hill T.J.
        • Steinke E.E.
        Sexual concerns of cardiac patients: predictors and the influence of specific sexual activities.
        Eur J Cardiovasc Nurs. 2015; 14: 45-52
        • Sardinha A.
        • Araujo C.G.
        • Soares-Filho G.L.
        • Nardi A.E.
        Anxiety, panic disorder and coronary artery disease: issues concerning physical exercise and cognitive behavioral therapy.
        Expert Rev Cardiovasc Ther. 2011; 9: 165-175
        • Friedman S.
        Cardiac disease, anxiety, and sexual functioning.
        Am J Cardiol. 2000; 86: 46F-50F
        • Assari S.
        Depression mediates the effect of sexual function on quality of life among men but not women with coronary artery disease.
        Int Cardiovasc Res J. 2014; 8: 171-177
        • Soares-Filho G.L.
        • Freire R.C.
        • Biancha K.
        • et al.
        Use of the hospital anxiety and depression scale (HADS) in a cardiac emergency room: chest pain unit.
        Clinics (Sao Paulo). 2009; 64: 209-214
        • Roose S.P.
        • Seidman S.N.
        Sexual activity and cardiac risk: is depression a contributing factor?.
        Am J Cardiol. 2000; 86: 38F-40F
        • Eifert G.H.
        • Thompson R.N.
        • Zvolensky M.J.
        • et al.
        The cardiac anxiety questionnaire: development and preliminary validity.
        Behav Res Ther. 2000; 38: 1039-1053
        • Sardinha A.
        • Nardi A.E.
        • Araujo C.G.
        • Ferreira M.C.
        • Eifert G.H.
        Brazilian Portuguese validated version of the Cardiac Anxiety Questionnaire.
        Arq Bras Cardiol. 2013; 101: 554-561
        • Zvolensky M.J.
        • Feldner M.T.
        • Eifert G.H.
        • Vujanovic A.A.
        • Solomon S.E.
        Cardiophobia: a critical analysis.
        Transcult Psychiatry. 2008; 45: 230-252
        • Reddy P.R.
        • Reinier K.
        • Singh T.
        • et al.
        Physical activity as a trigger of sudden cardiac arrest: the Oregon Sudden Unexpected Death Study.
        Int J Cardiol. 2009; 131: 345-349
        • Niederseer D.
        • Moller J.
        • Niebauer J.
        Increased rates of myocardial infarction and deaths in men after sexual activity.
        Int J Cardiol. 2012; 156: 234-235
        • Lee S.
        • Chae J.
        • Cho Y.
        Causes of sudden death related to sexual activity: results of a medicolegal postmortem study from 2001 to 2005.
        J Korean Med Sci. 2006; 21: 995-999
        • Muller J.E.
        Sexual activity as a trigger for cardiovascular events: what is the risk?.
        Am J Cardiol. 1999; 84: 2N-5N
        • Parzeller M.
        • Bux R.
        • Raschka C.
        • Bratzke H.
        Sudden cardiovascular death associated with sexual activity: a forensic autopsy study (1972-2004).
        Forensic Sci Med Pathol. 2006; 2: 109-114
        • Dahabreh I.J.
        • Paulus J.K.
        Association of episodic physical and sexual activity with triggering of acute cardiac events: systematic review and meta-analysis.
        JAMA. 2011; 305: 1225-1233
        • Muller J.E.
        Triggering of cardiac events by sexual activity: findings from a case-crossover analysis.
        Am J Cardiol. 2000; 86: 14F-18F
        • Muller J.E.
        • Mittleman M.A.
        • Maclure M.
        • Sherwood J.B.
        • Tofler G.H.
        Triggering myocardial infarction by sexual activity. Low absolute risk and prevention by regular physical exertion. Determinants of Myocardial Infarction Onset Study Investigators.
        JAMA. 1996; 275: 1405-1409
        • Moller J.
        • Ahlbom A.
        • Hulting J.
        • et al.
        Sexual activity as a trigger of myocardial infarction. A case-crossover analysis in the Stockholm Heart Epidemiology Programme (SHEEP).
        Heart. 2001; 86: 387-390
        • Rothenbacher D.
        • Dallmeier D.
        • Mons U.
        • et al.
        Sexual activity patterns before myocardial infarction and risk of subsequent cardiovascular adverse events.
        J Am Coll Cardiol. 2015; 66: 1516-1517
        • Drory Y.
        • Shapira I.
        • Fisman E.Z.
        • Pines A.
        Myocardial ischemia during sexual activity in patients with coronary artery disease.
        Am J Cardiol. 1995; 75: 835-837
        • Nehra A.
        • Jackson G.
        • Miner M.
        • et al.
        The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease.
        Mayo Clin Proc. 2012; 87: 766-778
        • Cheitlin M.D.
        Sexual activity and cardiac risk.
        Am J Cardiol. 2005; 96: 24M-28M
        • Strom B.L.
        Sexual activity and cardiac risk: overview of epidemiologic research methods.
        Am J Cardiol. 2000; 86: 5F-9F
        • Kontaras K.
        • Varnavas V.
        • Kyriakides Z.S.
        Does sildenafil cause myocardial infarction or sudden cardiac death?.
        Am J Cardiovasc Drugs. 2008; 8: 1-7
        • Baylin A.
        • Hernandez-Diaz S.
        • Siles X.
        • Kabagambe E.K.
        • Campos H.
        Triggers of nonfatal myocardial infarction in Costa Rica: heavy physical exertion, sexual activity, and infection.
        Ann Epidemiol. 2007; 17: 112-118
        • Kobayashi M.
        • Takata Y.
        • Goseki Y.
        • et al.
        A sudden cardiac death induced by sildenafil and sexual activity in an HIV patient with drug interaction, cardiac early repolarization, and arrhythmogenic right ventricular cardiomyopathy.
        Int J Cardiol. 2015; 179: 421-423
        • Becker K.
        • Skalabrin E.
        • Hallam D.
        • Gill E.
        Ischemic stroke during sexual intercourse: a report of 4 cases in persons with patent foramen ovale.
        Arch Neurol. 2004; 61: 1114-1116
        • Reynolds M.R.
        • Willie J.T.
        • Zipfel G.J.
        • Dacey R.G.
        Sexual intercourse and cerebral aneurysmal rupture: potential mechanisms and precipitants.
        J Neurosurg. 2011; 114: 969-977
        • Tomcsanyi J.
        • Marosi A.
        • Arabadzisz K.
        • Zsoldos A.
        • Bozsik B.
        Tako-tsubo syndrome associated with sexual intercourse.
        Int J Cardiol. 2007; 121: e28-e29
        • Ebrahim S.
        • May M.
        • Ben Shlomo Y.
        • et al.
        Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study.
        J Epidemiol Community Health. 2002; 56: 99-102
        • Banerjee A.
        Coital emergencies.
        Postgrad Med J. 1996; 72: 653-656
        • Giordano U.
        Catecholaminergic polymorphic ventricular tachycardia identified by 24 hours ECG monitor.
        Acta Med Mediterranea. 2013; 29: 425-427
        • Steinke E.E.
        • Mosack V.
        • Hill T.J.
        Change in sexual activity after a cardiac event: the role of medications, comorbidity, and psychosocial factors.
        Appl Nurs Res. 2015; 28: 244-250
        • Reid G.J.
        • Siu S.C.
        • McCrindle B.W.
        • Irvine M.J.
        • Webb G.D.
        Sexual behavior and reproductive concerns among adolescents and young adults with congenital heart disease.
        Int J Cardiol. 2008; 125: 332-338
        • Ueno M.
        The so-called coition death.
        Jpn J Legal Med. 1963; 127: 333-340
        • Fisher A.D.
        • Bandini E.
        • Corona G.
        • et al.
        Stable extramarital affairs are breaking the heart.
        Int J Androl. 2012; 35: 11-17
      1. Steinke EE, Hill TJ, Mosack V. Medication use and predictors of sexual activity in men and women with CVD [e-pub ahead of print]. J Am Assoc Nurse Pract http://dx.doi.org/10.1002/2327-6924. Accessed August 2, 2015.

        • Davis R.
        • Reveles K.R.
        • Ali S.K.
        • et al.
        Statins and male sexual health: a retrospective cohort analysis.
        J Sex Med. 2015; 12: 158-167
        • Ko D.T.
        • Hebert P.R.
        • Coffey C.S.
        • et al.
        Beta-blocker therapy and symptoms of depression, fatigue, and sexual dysfunction.
        JAMA. 2002; 288: 351-357
        • Nicolai M.P.
        • Liem S.S.
        • Both S.
        • et al.
        A review of the positive and negative effects of cardiovascular drugs on sexual function: a proposed table for use in clinical practice.
        Neth Heart J. 2014; 22: 11-19
        • Jackson G.
        Sexual intercourse and stable angina pectoris.
        Am J Cardiol. 2000; 86: 35F-37F
        • Schwartz B.G.
        • Kloner R.A.
        Drug interactions with phosphodiesterase-5 inhibitors used for the treatment of erectile dysfunction or pulmonary hypertension.
        Circulation. 2010; 122: 88-95
        • Swearingen D.
        • Nehra A.
        • Morelos S.
        • Peterson C.A.
        Hemodynamic effect of avanafil and glyceryl trinitrate coadministration.
        Drugs Context. 2013; 2013: 212248
        • Steinke E.E.
        How can heart failure patients and their partners be counseled on sexual activity?.
        Curr Heart Fail Rep. 2013; 10: 262-269
        • Marcuccilli L.
        • Casida J.J.
        • Peters R.M.
        • Wright S.
        Sex and intimacy among patients with implantable left-ventricular assist devices.
        J Cardiovasc Nurs. 2011; 26: 504-511
        • Eckman P.M.
        • Dhungel V.
        • Mandras S.
        • et al.
        Sexual function after left ventricular assist device.
        J Am Coll Cardiol. 2013; 61: 2021-2022
        • Merle P.
        • Maxhera B.
        • Albert A.
        • et al.
        Sexual concerns of patients with implantable left ventricular assist devices.
        Artif Organs. 2015; 39: 664-669
        • Dougherty C.M.
        • Thompson E.A.
        Intimate partner physical and mental health after sudden cardiac arrest and receipt of an implantable cardioverter defibrillator.
        Res Nurs Health. 2009; 32: 432-442
        • Vazquez L.D.
        • Sears S.F.
        • Shea J.B.
        • Vazquez P.M.
        Sexual health for patients with an implantable cardioverter defibrillator.
        Circulation. 2010; 122: e465-e467
        • Walker R.L.
        • Campbell K.A.
        • Sears S.F.
        • et al.
        Women and the implantable cardioverter defibrillator: a lifespan perspective on key psychosocial issues.
        Clin Cardiol. 2004; 27: 543-546
        • Fries R.
        • Konig J.
        • Schafers H.J.
        • Bohm M.
        Triggering effect of physical and mental stress on spontaneous ventricular tachyarrhythmias in patients with implantable cardioverter-defibrillators.
        Clin Cardiol. 2002; 25: 474-478
        • Fry K.M.
        • Gerhardt C.A.
        • Ash J.
        • et al.
        Lifetime prevalence of sexual intercourse and contraception use at last sex among adolescents and young adults with congenital heart disease.
        J Adolesc Health. 2015; 56: 396-401
        • Opic P.
        • Roos-Hesselink J.W.
        • Cuypers J.A.
        • et al.
        Sexual functioning is impaired in adults with congenital heart disease.
        Int J Cardiol. 2013; 168: 3872-3877
        • Vigl M.
        • Kaemmerer M.
        • Seifert-Klauss V.
        • et al.
        Contraception in women with congenital heart disease.
        Am J Cardiol. 2010; 106: 1317-1321
        • Vigl M.
        • Hager A.
        • Bauer U.
        • et al.
        Sexuality and subjective wellbeing in male patients with congenital heart disease.
        Heart. 2009; 95: 1179-1183
        • Myers J.
        • Prakash M.
        • Froelicher V.
        • et al.
        Exercise capacity and mortality among men referred for exercise testing.
        N Engl J Med. 2002; 346: 793-801
        • Brito L.B.B.
        • Ricardo D.R.
        • Araújo D.S.M.S.
        • et al.
        Ability to sit and rise from the floor as a predictor of all-cause mortality.
        Eur J Prev Cardiol. 2014; 21: 892-898
        • Coelho C.W.
        • Araújo C.G.
        Relação entre aumento da flexibilidade e facilitações na execução de ações cotidianas em adultos participantes de programa de exercício supervisionado.
        Rev Bras Cinentropom Desempenho Hum. 2000; 2: 31-41
        • Belardinelli R.
        • Lacalaprice F.
        • Faccenda E.
        • Purcaro A.
        • Perna G.
        Effects of short-term moderate exercise training on sexual function in male patients with chronic stable heart failure.
        Int J Cardiol. 2005; 101: 83-90
        • Carvalho T.
        • Gonzales A.I.
        • Sties S.W.
        • Carvalho G.M.
        Cardiovascular rehabilitation, ballroom dancing and sexual dysfunction.
        Arq Bras Cardiol. 2013; 101: e107-e108
        • World Health Organization
        Defining Sexual Health: Report of a Technical Consultation on Sexual Health. Vol 30. World Health Organization, Geneva2002
        • Galinsky A.M.
        • McClintock M.K.
        • Waite L.J.
        Sexuality and physical contact in National Social Life, Health, and Aging Project Wave 2.
        J Gerontol B Psychol Sci Soc Sci. 2014; 69: S83-98
        • Byrne M.
        • Doherty S.
        • Murphy A.W.
        • McGee H.M.
        • Jaarsma T.
        Communicating about sexual concerns within cardiac health services: do service providers and service users agree?.
        Patient Educ Couns. 2013; 92: 398-403
        • Nicolai M.P.
        • Both S.
        • Liem S.S.
        • et al.
        Discussing sexual function in the cardiology practice.
        Clin Res Cardiol. 2013; 102: 329-336
        • Marijon E.
        • Bougouin W.
        • Perier M.C.
        • Celermajer D.S.
        • Jouven X.
        Incidence of sports-related sudden death in France by specific sports and sex.
        JAMA. 2013; 310: 642-643
        • Beutel M.E.
        • Weidner W.
        • Brahler E.
        Epidemiology of sexual dysfunction in the male population.
        Andrologia. 2006; 38: 115-121
        • Ginsberg T.B.
        • Pomerantz S.C.
        • Kramer-Feeley V.
        Sexuality in older adults: behaviours and preferences.
        Age Ageing. 2005; 34: 475-480