Is it okay to resume sex after a recent heart attack?

Maintaining or increasing the frequency of sexual activity within the first few months following a first acute MI episode is strongly associated with improved long-term survival regardless of pre-MI sexual activity frequency, a study suggests.

“Sexuality and sexual activity are markers of wellbeing,” said study author Professor Yariv Gerber from Tel Aviv University, Israel, in a press release. “Resumption of sexual activity soon after a heart attack may be a part of one’s self-perception as a healthy, functioning, young, and energetic person. This may lead to a healthier lifestyle generally.”

However, most adults reduce the frequency of, or even avoid, sexual activity following a heart attack, despite evidence supporting the safety of resuming sexual activity post-MI. [Circulation 2012;125:1058-1072; J Am Coll Cardiol 2011;57:e215-e367; Circulation 2013;128:2075-2096] “[The] primary reasons [are] fear that sex could trigger another MI or be fatal, depression, and physical limitations (including sexual dysfunction),” said Gerber and colleagues.

Although they have previously reported reduced long-term mortality risk associated with engagement in any level of sexual activity, [Am J Med 2020;133:100-107] the researchers noted that they did not explore the prognostic role of sexual activity shortly after MI. “[We did] not address the survival benefit of early sexual activity resumption.”

As such, the team pulled data from ISFAMI* comprising interviews of 495 sexually active patients (mean age 53 years, 90 percent male) conducted during index hospitalization (1992–93) and 3–6 months thereafter. Over a median follow-up of 22 years, 43 percent of participants had died. [Eur J Prev Cardiol 2020;doi:10.1093/eurjpc/zwaa011]

After the MI (median 4 weeks), 53 percent of participants either maintained (n=179) or increased (n=84) their pre-MI sexual activity frequency. The remaining 47 percent either reduced the frequency of (n=171) or completely abstained from (n=61) sexual activity.

Compared with reducing frequency of/abstaining from sexual activity, maintaining/increasing sexual activity frequency shortly after MI was inversely associated with all-cause mortality (hazard ratio [HR], 0.65), more so with non-CVD death (HR, 0.56).

Bouncing back

Resuming sexual activity shortly after MI may be a marker for better recovery, noted Gerber. “Improved physical fitness, stronger spouse relations, and a mental ability to ‘bounce back’ from the initial shock of the event within a few months are among the possible explanations for the survival benefit observed among the maintained/increased group.”

Conversely, those who perceive their health as poor may be less likely to resume sexual activity, he added. “[These patients] may also be less likely to adhere to cancer screening tests and other prevention practices during follow-up.” This may explain the strong inverse association between maintaining/increasing sexual activity frequency and cancer mortality seen in a more refined cause-specific analysis (HR, 0.44).

Communication is key

Practice guidelines advocate sexual counselling shortly after MI. However, not all patients are comfortable with it, and most who get counselled are apparently advised against resuming sexual activity. [Circulation 2014;130:2302-2309] “Given that the medical and psychological barriers for resumption are at least, in part, modifiable, patient-physician communication on sexual matters may serve as a critical factor in the preservation or loss of sexual activity for a considerable fraction of patients,” said the researchers.

“[Overall, the findings] provide new insight into the survival benefit of sexual activity, highlighting the importance of its resumption after a major event such as MI,” they added. “These findings should serve to reduce unsubstantiated patient concerns and support a recommendation to return to their usual level of sexual activity soon after a heart attack.”

Nonetheless, the sensitive nature of the study might have introduced participation bias. “The reliability of self-reporting [may have been confounded by] factors including age, ethnicity, number of sexual partners, and time frame for recall,” they added. The predominantly male cohort and relatively young age of participants may also limit generalizability of the findings.