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Canadian Journal of Cardiology

Sexual Counselling in Cardiac Rehabilitation: An Urgent Need for More Consideration and Study

      Sexual problems in patients with heart disease (HD) are common and occur primarily because of one or more of the following reasons: (1) lack of knowledge about sexual aspects associated with HD and cardiovascular drugs;
      • Joseph P.
      • Lonn E.
      • Bosch J.
      • et al.
      Long-term effects of statins, blood pressure-lowering, and both on erectile function in persons at intermediate risk for cardiovascular disease: a substudy of the heart outcomes prevention evaluation-3 (HOPE-3) randomized controlled trial.
      • Steptoe A.
      • Jackson S.E.
      • Wardle J.
      Sexual activity and concerns in people with coronary heart disease from a population-based study.
      (2) fear that sexual activity might induce angina, palpitations, or death;
      • Levine G.N.
      • Steinke E.E.
      • Bakaeen F.G.
      • et al.
      Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association.
      (3) changes in the relationship between patients and their partners after a cardiac event;
      • Steinke E.E.
      • Jaarsma T.
      • Barnason S.A.
      • et al.
      Sexual counselling 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).
      and (4) the coexistence of psychological problems such as anxiety or depression.
      • Mulat B.
      • Arbel Y.
      • Mashav N.
      • et al.
      Depressive symptoms and erectile dysfunction in men with coronary artery disease.
      Actually, evidence suggests that sexual activity might decrease because patients tend to be psychologically distressed and fearful of an unpleasant symptom or a potential heart attack during sex.
      • D'Eath M.
      • Byrne M.
      • Murphy P.
      • et al.
      Participants' experiences of a sexual counseling intervention during cardiac rehabilitation: a nested qualitative study within the CHARMS pilot randomized controlled trial.
      For the couple, there are several physical and psychological factors that result in an impairment of their sexuality as well as sexual dysfunction.
      • Steinke E.E.
      • Jaarsma T.
      • Barnason S.A.
      • et al.
      Sexual counselling 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).
      • Jaarsma T.
      Sexual function of patients with heart failure: facts and numbers.
      Could we expect that patients with HD attending cardiac rehabilitation (CR) programs will improve their sexual activity? Although initially most of us would consider it likely to be true, this very relevant topic has been scarcely investigated and discussed in the literature. First of all, sexual activity should be recognized as a type of exercise.
      • Araujo C.G.
      Sexual activity: an exercise to prevent cardiovascular morbidity and mortality?.
      • Stein R.
      • Hohmann C.B.
      Sexual activity and the heart.
      Second, it is clear that the vast majority of patients with HD who attend a CR program improve their functional capacity and aerobic and musculoskeletal fitness,
      • Travensolo C.
      • Goessler K.
      • Poton R.
      • Pinto R.R.
      • Polito M.D.
      Measurement of physical performance by field tests in programs of cardiac rehabilitation: a systematic review and meta-analysis.
      • Signorelli G.R.
      • Duarte C.V.
      • Ramos P.S.
      • Araújo C.G.S.
      Melhoria da capacidade funcional excede a da condição aeróbica: dados de 144 pacientes de programa de exercício.
      and, therefore, would be easily able to carry out sexual activities. In our clinical experience, CR participation also improves health-related self-confidence and general self-efficacy and body image, presenting an indirect positive effect in diminishing health-related fears associated with sexual activity after a cardiac event. In addition, the partner’s active involvement in CR (eg, having the partner observing the patient’s performance during the preadmission exercise testing) tends to substantially reduce health-related anxiety in the couple. It is also a timely chance to clarify sexual and health-related doubts and misconceptions.
      In this issue of the Canadian Journal of Cardiology (CJC), Boothby et al.
      • Boothby C.A.
      • Dada B.R.
      • Rabi D.M.
      • Campbell T.S.
      • Tang K.L.
      The effect of cardiac rehabilitation attendance on sexual activity outcomes in cardiovascular disease patients: a systematic review.
      published a systematic review addressing the impact of CR attendance in sexual activity outcomes in adult patients with HD. They identified and selected 14 studies: 3 prospective cohort studies, 6 randomized, and 5 nonrandomized controlled trials.
      • Boothby C.A.
      • Dada B.R.
      • Rabi D.M.
      • Campbell T.S.
      • Tang K.L.
      The effect of cardiac rehabilitation attendance on sexual activity outcomes in cardiovascular disease patients: a systematic review.
      Although a meta-analysis was not possible due to the wide variability of methods and protocols used in these studies, a semiquantitative approach yielded conflicting results. Attending CR tended to promote a positive effect in improving sexual functioning and frequency. Results regarding sexual resumption and satisfaction, however, were not consistent. Finally, as expected from the paucity of literature on the topic, they concluded that the primary question remains unanswered and further studies are needed.
      • Boothby C.A.
      • Dada B.R.
      • Rabi D.M.
      • Campbell T.S.
      • Tang K.L.
      The effect of cardiac rehabilitation attendance on sexual activity outcomes in cardiovascular disease patients: a systematic review.
      Therefore, the authors
      • Boothby C.A.
      • Dada B.R.
      • Rabi D.M.
      • Campbell T.S.
      • Tang K.L.
      The effect of cardiac rehabilitation attendance on sexual activity outcomes in cardiovascular disease patients: a systematic review.
      should be congratulated for approaching such a relevant topic and it is surprising that this has been so poorly studied in medical literature. As they pointed out, certainly more high-quality studies are needed in this topic. Notwithstanding, it should be recognized that many real-life issues prevent an adequate research approach to this primary topic. To get a better appraisal of these difficulties, some aspects regarding CR, sexual activity, and their interplay should be taken into account.
      Although CR is a widely used expression in the medical field, it generally refers to a large variance of programs and protocols in hospitals and medical centres around the world. In the late 1950s, a seminal study published in JAMA conducted by Hellerstein and Ford
      • Hellerstein H.K.
      • Ford A.B.
      Rehabilitation of the cardiac patient.
      attracted a lot of attention and promoted CR. According to their statement,
      • Hellerstein H.K.
      • Ford A.B.
      Rehabilitation of the cardiac patient.
      “the process of rehabilitation begins at the moment the patient is first stricken with his disease and the goal is the maximal attainment within the patient’s capacities.” If 60 years ago this was a substantial paradigm shift—opposed to the classical 6-week bed-rest approach after an acute myocardial infarction—nowadays the expectations go far beyond heart rehabilitation, even for the most elderly and frail patient with HD.
      • Nishijuka F.A.
      • Silva e Souza C.G.
      • Duarte C.V.
      • Araujo C.G.S.
      Pre-participation physical fitness does not influence adherence to a supervised exercise program.
      It is reasonable to expect that an adherent CR patient would not only regain previous capacities but considerably improve physical and mental health, to prevent another cardiac event. Corroborating this idea, a recent Italian study found significantly lower cardiac hospitalizations with and without mortality in patients with HD who attended a 5-month CR program.
      • Doimo S.
      • Fabris E.
      • Piepoli M.
      • et al.
      Impact of ambulatory cardiac rehabilitation on cardiovascular outcomes: a long-term follow-up study [Epub ahead of print].
      Targeting these lifelong goals, patients with HD might ideally enroll in long-term, comprehensive programs including regular exercise, risk factor modification, psychological support, and appropriate use of cardiovascular drugs. This recent “lifestyle” approach usually requires a multiprofessional team, focusing not only on rehabilitation but also on overall improvement in patients’ health-related quality of life.
      Methodological challenges also exist regarding research on sexual activity. The first struggle is to operationally define it. In a study formerly published in the CJC,
      • Stein R.
      • Sardinha A.
      • Araujo C.G.
      Sexual activity and heart patients: a contemporary perspective.
      we described sexual activity as a broad concept that varies considerably among cultures, encompassing a variety of behaviours. Using the initials of each of the following behaviours—kissing (K), touching (T), oral sex (O), masturbation (M), and intercourse (I)—we came out with the expression KiTOMI. The acronym proved to be useful to advice sexual activity for a given clinical heart condition (eg, KiT—only kissing and touching recommended, KiTOM—all behaviours recommended with the exception of intercourse).
      • Stein R.
      • Sardinha A.
      • Araujo C.G.
      Sexual activity and heart patients: a contemporary perspective.
      This approach could be possibly useful to more accurately define sexual activity in research protocols.
      Another important issue that Boothby et al.
      • Boothby C.A.
      • Dada B.R.
      • Rabi D.M.
      • Campbell T.S.
      • Tang K.L.
      The effect of cardiac rehabilitation attendance on sexual activity outcomes in cardiovascular disease patients: a systematic review.
      had to cope with was the variant profiles of patients attending CR. These patients could be men or women from a broad age range and with different clinical presentations. Sexual dysfunction, per se, is quite prevalent among aging individuals,
      • Twenge J.M.
      • Sherman R.A.
      • Wells B.E.
      Declines in sexual frequency among American adults, 1989-2014.
      and negatively impacts their health-related quality of life, psychological well-being, marital quality, and risk for adverse cardiovascular events. This is particularly true and likely more prevalent in middle-aged and older patients with HD, who often combine high levels of anxiety and stress, low physical fitness, unhealthy body composition, excess alcohol intake, smoking, and regular use of cardiovascular drugs.
      • Lunelli R.P.
      • Rabello E.R.
      • Stein R.
      • Goldmeier S.
      • Moraes M.A.
      Sexual activity after myocardial infarction: taboo or lack of knowledge?.
      This variability could likely influence their sexual activity pattern before and after a cardiac event, also producing diverse expectations and struggles about sex. In this sense, the perceived impact of attending CR on sexual activity might vary widely among the different profiles of CR patients. As most of the data were obtained by self-report, pre-event condition, expectations and personal attitudes about sex are probably variables that should be considered as covariates aimed to compare pre- and post-CR outcomes in sexual activity.
      Additionally, it remains unclear if the benefits in sexual activity outcomes after attending a CR program shown by Boothby et al.
      • Boothby C.A.
      • Dada B.R.
      • Rabi D.M.
      • Campbell T.S.
      • Tang K.L.
      The effect of cardiac rehabilitation attendance on sexual activity outcomes in cardiovascular disease patients: a systematic review.
      were due to improvements in aerobic musculoskeletal fitness, to sexual counseling, or both. It is still controversial whether the addition of a formal sexual counselling intervention in the context of CR is actually necessary to improve sexual function for these patients.
      • Steinke E.E.
      • Jaarsma T.
      • Barnason S.A.
      • et al.
      Sexual counselling 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).
      A Cochrane systematic review published in 2016
      • Byrne M.
      • Doherty S.
      • Fridlund B.G.
      • et al.
      Sexual counselling for sexual problems in patients with cardiovascular disease.
      found only 3 trials about this topic. Of these, 1 proposed a highly intensive intervention (eg, 5 hours of sexual therapy provided by a sex therapist) to effectively decrease the time taken to resume sexual activity after a cardiac event, and to improve self-reported sexual function and satisfaction.
      • Klein R.
      • Bar-on E.
      • Klein J.
      • Benbenishty R.
      The impact of sexual therapy on patients after cardiac events participating in a cardiac rehabilitation program.
      Unfortunately, although an attractive proposal, it is unlikely that this type of intervention could be implemented as part of a routine CR program in most health care systems. In reality, as reported by a multi-institutional consensus document,
      • Steinke E.E.
      • Jaarsma T.
      • Barnason S.A.
      • et al.
      Sexual counselling 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).
      sexual problems are rarely addressed during CR because of time and resource limitations, as well as staff-related barriers such as lack of specific professional training, low knowledge and confidence, and personal discomfort with sexual issues. A promising sexual counselling pilot multilevel intervention for CR settings recently proposed
      • Murphy P.J.
      • Mc Sharry J.
      • Casey D.
      • et al.
      Sexual counselling for patients with cardiovascular disease: protocol for a pilot study of the CHARMS sexual counselling intervention.
      the CHARMS pilot study, highlighting the importance of targeting not only patients and partners but also creating resources for staff members to adequately address sexual issues within CR participants. Staff training should include the promotion of knowledge, awareness, and confidence in delivering sexual assessment and counselling, as well as openness to discuss the patients’ sexual problems.
      Although CR with or without specific sexual counselling seem to positively impact sexual activity outcomes in patients with HD, sexuality is indeed a challenging aspect of human experience. Data from sexual dysfunction studies signalize that, considering erectile dysfunction in noncardiac patients, for example, even the first-choice intervention (sexual psychotherapy + phosphodiesterase-5 inhibitors) yields only moderate effects.
      • Schmidt H.M.
      • Munder T.
      • Gerger H.
      • Fruhauf S.
      • Barth J.
      Combination of psychological intervention and phosphodiesterase-5 inhibitors for erectile dysfunction: a narrative review and meta-analysis.
      Thus, it seems unlikely that standardized sexual counselling protocols in the context of CR could effectively treat sexual dysfunctions secondary to HD. It is likely that the target of sexual counselling in CR would more properly be to raise awareness in patients, partners, and staff members to better identify and refer patients to specific treatment, as well as to prevent health-related sexual anxiety and sexual dysfunction. Future studies are surely needed to clarify this relevant point as well as to determine best practices and strategies for sexual counselling in CR.
      In summary, the paper by Boothby et al.
      • Boothby C.A.
      • Dada B.R.
      • Rabi D.M.
      • Campbell T.S.
      • Tang K.L.
      The effect of cardiac rehabilitation attendance on sexual activity outcomes in cardiovascular disease patients: a systematic review.
      is a well-conducted and updated systematic review of sexual activity within a CR program. If sexual counselling should become a formal part of a comprehensive CR program, and if so, how should it be implemented is still under debate. However, health professionals and, in particular, cardiologists should be aware of the need to discuss and to offer prompt and adequate advice regarding sexual life for patients with HD. This could be carried out by the CR team or, if felt appropriate, by referral to a professional specialist in sexuality.

      Disclosures

      R. Stein is recipient of a research scholarship from CNPq - Brasília/Brazil. All authors declare that they have no relevant conflicts of interest to disclose.

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