MOST HEART SPECIALISTS are hardly Dr Ruth — sex is not something they relish bringing up with patients. But new guidance says they should, early and often, to let survivors know intimacy is often possible after a heart attack.

Discussions should involve everything from when and how to resume sex, to what position might be best for some conditions or not advised for others, according to a consensus statement released by the American Heart Association and the European Society of Cardiology.

It’s billed as the first scientific statement with detailed guidance on resuming sex after a heart attack, stroke or other cardiac condition and is based on a review of medical literature.

“Sexual health is an important part of the overall health of the individual,” even for the oldest patients, said Elaine Steinke, a researcher and professor of nursing at Wichita State University in Kansas. Steinke was the lead author of the statement published in the heart association’s Circulation journal and the European Heart Journal.

Co-author Tiny Jaarsma, a professor and heart failure researcher at Sweden’s Linkoping University, said in an email that doctors and nurses “rarely discuss sex ‘spontaneously’, but often wait until the patient brings up questions around sex.”

Health care providers often are afraid to upset patients or might feel embarrassed themselves.

Fears and anxieties about resuming sex are often numerous: Will it cause another heart attack? Can I use Viagra? What if my defibrillator goes off during sex? And many are too shy to ask, so heart doctors, nurses and other health care workers should take the lead and initiate the discussion with men and women patients of all ages and their partners, according to the statement.

Many heart patients can safely resume sexual intercourse after first checking with their doctors, and the answers to many questions depend on each patient’s overall health, the guidance says. Patients with mild, stable chest pain face a low risk for a sex-triggered heart problem, whereas patients with advanced heart failure should postpone sex until their condition is stabilized.

General precautions listed in the statement include:

• Before resuming sex, make sure you can engage in moderate physical activity, such as walking briskly up two flights of stairs, without chest pain, breathlessness or other symptoms.
• If moderate activity is too strenuous, avoid intercourse but not intimacy: hugging and kissing may be OK.
• Have sex in a comfortable, familiar place and avoid things that could add stress to the experience, including extramarital affairs.
• Tell your doctor about any symptoms during sex, including chest pain, dizziness or insomnia afterward.
• Some positions may not be safe. Heart bypass surgery patients should avoid being on top in the missionary position, and Steinke said having sex in a more “upright position” may be easier for some heart failure patients, whose symptoms may include shortness of breath.

Ruth Westheimer, the famed 85-year-old sex therapist known as “Dr Ruth,” commented on the study Monday through her publicist from Switzerland, where she was hiking.

When hospitals have invited her to speak, she always gives the same message: “Doctors need to ask their patients about sexual functioning,” even if both sides are embarrassed by the topic.

“When it comes to sex and heart issues, in my experience it’s as likely to be the partner of the heart patient who is afraid of having sex because it might cause a heart attack as the patient him or herself,” Westheimer said. “What I suggest is that people write down their questions and send it to the doctor in advance of their appointment. That way they’ll be sure the question gets asked and the doctor will have had time to get prepared to answer it.”

Dr Vijay Divakaran, a cardiologist with Scott & White Hospital in Round Rock, Texas, said the consensus statement is important and will change practice. Cardiologists don’t get formal training in discussing sexual issues with their patients but the conversations get easier, he said

“Sometimes patients don’t talk about it, they just Google it, and there’s a lot of misconceptions” online, Divakaran said. “Once you start asking them, you would be surprised that it almost always is an issue.”

- Lindsey Tanner

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