A 56-year-old man is brought to the emergency department with a 4-hour history of crushing, substernal chest pain. His ECG shows a 3-mm ST-segment elevation in leads V2-V4. He is taken for cardiac catheterization and undergoes primary angioplasty and stenting of the occluded mid-left anterior descending artery. There is 30%-40% stenosis of the right coronary artery that does not require intervention. After the procedure, the patient is admitted to the coronary care unit. Echocardiogram shows mild anterior wall hypokinesis and a normal left ventricular ejection fraction. He remains chest pain free throughout his 3-day hospital stay. The patient is started on dual antiplatelet therapy. He begins a progressive supervised activity program, which is uneventful, and he is subsequently discharged home. At a follow-up appointment 3 weeks later, he reports that he has been walking for 20 minutes each day without any problems. The patient occasionally has some bleeding when brushing his teeth, but is otherwise asymptomatic. He asks whether it would be safe for him to resume sexual activity. Which of the following is the most appropriate recommendation?

Question

A 56-year-old man is brought to the emergency department with a 4-hour history of crushing, substernal chest pain.  His ECG shows a 3-mm ST-segment elevation in leads V2-V4.  He is taken for cardiac catheterization and undergoes primary angioplasty and stenting of the occluded mid-left anterior descending artery.  There is 30%-40% stenosis of the right coronary artery that does not require intervention.  After the procedure, the patient is admitted to the coronary care unit.  Echocardiogram shows mild anterior wall hypokinesis and a normal left ventricular ejection fraction.  He remains chest pain free throughout his 3-day hospital stay.  The patient is started on dual antiplatelet therapy.  He begins a progressive supervised activity program, which is uneventful, and he is subsequently discharged home.  At a follow-up appointment 3 weeks later, he reports that he has been walking for 20 minutes each day without any problems.  The patient occasionally has some bleeding when brushing his teeth, but is otherwise asymptomatic.  He asks whether it would be safe for him to resume sexual activity.  Which of the following is the most appropriate recommendation?

Quizplus · Accepted Answer

Explanation: Patients with cardiac disease are often anxious about their ability to engage in sexual activity, especially after a myocardial infarction (MI). Sexual activity is associated with an increase in heart rate and blood pressure, and a small but measurable absolute increase in the risk of MI. Studies have estimated the cardiovascular exertion of sexual activity to be relatively modest, in the range of 3-4 metabolic equivalents. metabolic equivalents In general, based on cardiovascular disease (CVD) status, patients can be classified into 3 categories with regard to sexual activity: Low-risk patients can perform light-intensity exercise without symptoms and should be able to initiate or resume sexual activity. Examples include those with few CVD risk factors, controlled hypertension, asymptomatic left ventricular dysfunction, or successful revascularization of clinically significant lesions (>50%-60%). High-risk patients should be referred for a detailed assessment prior to advising on activity. Examples include those with refractory angina, New York Heart Association class IV heart failure, significant arrhythmias, or severe valvular disease. For indeterminate/intermediate-risk patients, stress testing is recommended to reclassify them as low- or high-risk and to help guide decisions. In the period immediately following an acute MI, the myocardium may be vulnerable to increases in demand. Nonetheless, MI patients who have undergone successful revascularization or have no evidence of ischemia on exercise testing can be considered low-risk. They may safely resume sexual intercourse soon after the MI, within 3-4 weeks (Princeton guidelines) and possibly as early as 1 week (American Heart Association guidelines). (Choice B) Dual antiplatelet therapy is not a contraindication to physical activity. It is not unusual for patients on dual antiplatelet therapy to experience a small amount of bleeding when brushing their teeth or shaving; they can be counseled to use a soft toothbrush or an electric razor. (Choices C and D) This patient had successful revascularization, an uncomplicated hospital course, and normal left ventricular function with mild anterior wall hypokinesis (likely myocardial stunning) on echocardiogram. More than 3 weeks after his MI, he is asymptomatic and able to perform moderate walking (corresponding to sexual intercourse in metabolic equivalents). He can be classified as a low-risk patient and should be able to resume sexual activity at this time without further stress testing; he does not need to defer sexual activity to allow for myocardial remodelling. (Choice E) The patient may participate in cardiac rehabilitation, but this should not impact his ability to engage in sexual activity, especially if he remains asymptomatic. Educational objective: Patients who are at low risk of developing cardiovascular complications can initiate or resume sexual activity soon after myocardial infarction. References: Sexual activity and cardiovascular disease: a scientific statement from the American Heart Association. (http://www.ncbi.nlm.nih.gov/pubmed/22267844) The second Princeton consensus on sexual dysfunction and cardiac risk: new guidelines for sexual medicine. (http://www.ncbi.nlm.nih.gov/pubmed/16409215) The Princeton III Consensus recommendations for the management of erectile dysfunction and cardiovascular disease. (http://www.ncbi.nlm.nih.gov/pubmed/22862865)

A 56-Year-Old Man Is Brought to the Emergency Department with a 4-Hour