New Zealand has the sixth-highest rate of death from heart disease in the developed world.
Since the 1980s, survival rates from heart attacks have improved - a lot of people get them, but more and more people are surviving. A recent study of patients in Denmark showed that in 1984-1988 31.4 per cent of patients died within a month of having a heart attack. From 2004-2008 this was down to 14.8%.
Once a patient has made it through a heart attack and begins to recover, they get advice from their doctors on what to do to stay healthy and get back to normal. That includes a lot of things - when to go back to work, when they can start traveling again and what to eat. But there is an important item that a lot of doctors don't talk about: sex.
There are no universal guidelines for getting back to 'normal'
Providing advice about lifestyle can be more challenging than prescribing standardised medications or smoking cessation because "normal" life differs widely among patients and requires individualized counseling.
For instance, scientific evidence from large-scale clinical trials isn't always available to help the cardiologist decide the ideal time for when an individual patient should return to work. A software engineer might get different advice than a butcher or construction worker who has to lift heavy objects all day long. Physicians have to carefully estimate the patient's capacity for physical activity as well as the physical demands of the job and be pragmatic about how long a patient can take time off from work.
Sex also requires this kind individualised counseling. New research shows that patients want to talk about sexual activity with their doctors, but that all too often that conversation never takes place.
Let's talk about sex
A recent study conducted in 127 hospitals in the United States and Spain suggests that doctors are not very good at broaching the topic of sexual activity after a heart attack.
Researchers studied 2,349 women and 1,152 men who had suffered from a myocardial infarction (the medical term for a heart attack). This study focused on younger heart attack patients (ages 18-55) and asked them whether they had discussed sexual activity with their doctors. With younger patients talking about life after a heart attack is especially important. The loss of sexual activity or function is a major quality of life issue, and can affect intimate relationships, reproduction and lead to depression.
In the month following the heart attack, only 12 per cent of women and 19 per cent of men had some discussion with a doctor about sex. In the US, most patients reported that they initiated the discussion, whereas in Spain, most discussions were initiated by the doctor. This means that more than 85 per cent of patients received no advice from their doctors regarding if and when they could resume sexual activity.
The study found that the vast majority of patients were sexually active in the year before their heart attacks, and they valued sexuality as an important part of life. They also felt it was appropriate for physicians to initiate the discussion about having sex again.
It is interesting that in the US, patients were more likely to bring up sex and men were given more restrictive advice, while in Spain, physicians were more likely to bring up the topic and more restrictive recommendations were given to women.
The study did not specifically study the motivations of the physicians but these differences suggest that cultural differences and gender affect the counseling in regards to sexual activity. Future research could potentially also study the physicians and help uncover how culture and gender influence the counseling process.
This lack of communication between doctors and patients was not due to the patients' unease: 84% of women and 91 per cent of men said that they would feel comfortable talking to their doctors about sex. What is even more concerning is that the 15% or so of patients who received counseling often got inaccurate recommendations.
Sex is exercise. But doctors don't talk about it that way
Two-thirds of those who talked about sex with their doctors were told that they could resume sexual activity with restrictions like limiting sex, taking a "passive role" or keeping their heart rate down during sex. But here's the thing: sex is exercise. And after a heart attack doctors routinely ask patients whether they can tolerate mild to moderate physical activity such as mowing the lawn or climbing up two flights of stairs without chest pain or other major symptoms.
The Scientific Statement of the American Heart Association (AHA) on sexual activity states that it is reasonable to resume sexual activity as early as one week after an uncomplicated heart attack. If there are complications after the heart attack such as feeling out of breath or experiencing persistent chest pain then these problems need to be addressed first. And in the AHA guidelines there is no mention of "passive roles" or keeping heart rates down during sex. These restrictions are also quite impractical. How are patients supposed to monitor their heart rates and keep them down during sex?
The kind of restrictions recommended by doctors in the study - and presumably by medical practitioners who weren't polled - are not backed up by science and place an unnecessary burden on a patient's personal life. Hopefully, after reading the results of this study, doctors will take a more pro-active role and address the topic of sex with their heart attack patients with proper recommendations instead of leaving patients in a state of uncertainty. If a patient can handle moderate exercise, they can probably handle sex.
Jalees Rehman is an Associate Professor of Medicine and Pharmacology at University of Illinois at Chicago.