Can sex cause a heart attack?

If movies and soap operas are anything to go by, sex can be dangerous for people with heart conditions.

While research shows that sex can indeed trigger heart attacks in some people, especially men, the odds of literally succumbing to passion are very low. Sexual activity is a contributing factor in less than 1 percent of heart attacks, according to a 1996 study by Harvard Medical School researchers.

Although heart attacks during sex are rare, no one wants to be among the unlucky few who die while getting lucky. So if you have cardiovascular disease (CVD), or even if it runs in your family, it's important to ask your doctor what type of sexual activity is safe. If you've just had a heart attack, for instance, you should wait three to four weeks before having intercourse, according to current guidelines.

And if you have heart failure, your doctor may recommend that you avoid lying on your back during sex, because fluid is more likely to pool in your lungs in that position. Health.com: Heart health step-by-step

The physical danger posed by sexual activity is probably the least of your problems, however. There are plenty of other ways for heart disease to curtail your sex life. Everything from incision pain following bypass surgery to the emotional stress of living with a heart condition can get in the way of intimacy.

Sexual activity and heart conditions can interact in complicated ways, which can be difficult to tease apart. To make matters worse, heart patients (and their partners) are often uncomfortable discussing their sex lives with their doctors and vice versa.

"I've found that most doctors don't have the time -- or the personality -- to talk about sex with their heart patients," says Dr. Edward Chapunoff, a cardiologist in private practice in Pompano Beach, Florida, and the author of "Answering Your Questions About Heart Disease and Sex."

"They are evasive about it," he said. "They won't bring it up themselves and even if the patient brings it up, a doctor might be hesitant to discuss it."

So what's a heart patient to do? Prepare a list of intimacy questions in advance of your next checkup and don't let your doctor's squirming deter you. In the meantime, here are some answers to three not-so-frequently asked questions about sex and heart disease.

Is my sexual dysfunction related to my heart?

The link between cardiovascular disease and sexual dysfunction is well established, at least in men. Researchers have known for years that erectile dysfunction (ED) is disproportionately common among men with CVD (and even among those with risk factors for CVD, such as diabetes and high blood pressure). While erectile dysfunction can result from a number of factors, including psychological ones, the majority of cases can be traced to vascular problems.

The shared mechanism linking ED and CVD is believed to originate in the endothelium, the thin layer of cells that lines blood vessels. Risk factors such as high cholesterol, high blood pressure, and cigarette smoking prevent cells in the endothelium from releasing nitric oxide. This compromises the ability of blood vessels to dilate, which can lead to both atherosclerosis and erectile dysfunction. Health.com: 10 best foods for your heart

Atherosclerosis, the hardening and narrowing of the arteries that causes coronary heart disease, can affect the arteries that pump blood into the penis just as readily as those that surround the heart. But endothelial problems can also prevent the so-called smooth muscle in the penis from relaxing properly. In either case, erections become harder to sustain.

For a long time it was thought that ED was strictly a side effect of CVD and atherosclerosis, but experts now believe that ED may actually precede heart problems. A 2005 study in the Journal of the American Medical Association described ED as a "harbinger" of cardiovascular events.

The study, which analyzed more than 4,000 men without symptoms of CVD or ED, found that the men who subsequently experienced ED were nearly 50 percent more likely than those who did not to experience a cardiovascular event within seven years.

"It's important to know that just looking fine doesn't necessarily mean you have a healthy heart," says Chapunoff. "It's important that both the patient and their partner talk to their doctor about any sexual dysfunction, because it could signal a cardiac problem."

In women, the relationship between CVD and sexual dysfunction is less clear. Although sexual dissatisfaction in women has been linked to peripheral arterial disease, the mechanisms of female sexual function are thought to be less intertwined with the cardiovascular system.

Do my heart meds have any sexual side effects?

If your heart doesn't cause you problems in the bedroom, the medicine you take to keep it healthy might. Several medications commonly prescribed to heart patients can have sexual side effects in both men and women, including ED and loss of libido.

Two kinds of cholesterol-lowering drugs, fibrates and statins, have been linked with ED, but it is mainly blood-pressure medications that are believed to contribute to sexual dysfunction. Health.com: 7 causes of high cholesterol

Beta-blockers, calcium channel blockers, angiotensin-II receptor antagonists, and diuretics are all associated with ED. Although some experts have argued that hypertension itself is responsible for ED, a 2007 study in the International Journal of Impotence Research found that men taking angiotensin-II receptor antagonists were twice as likely to experience ED than men whose hypertension was untreated. Another study of nearly 1,400 men determined that taking hypertension drugs (diuretics, beta-blockers, methyldopa, or clonidine) increased the odds of experiencing ED by 2.5 times.

Blood-pressure medications are also known to cause sexual dysfunction in women, although the phenomenon hasn't been studied as extensively as it has in men. One reason for the disparity may be that the most common symptoms in women -- loss of libido, inadequate lubrication -- are more subtle than ED.

When Liz Saldana, 48, the owner of an online magazine and store in Tampa, Florida, first started taking a beta-blocker, she saw her sex drive shrink significantly.

"I went from being a really vibrant woman to someone who could just live without it," she says. "When my husband initiated anything, my attitude became, 'Oh damn, do we have to do this?'"

She was too embarrassed to bring up the issue with her doctor. "Initially I thought my lack of sex drive pertained to all of the stress I was under, not to my heart medications," says Saldana, who was on the beta-blocker Toprol-XL (metoprolol) before suffering a heart aneurysm in July. "None of my doctors explained that it could be a side effect of what I was on."

It wasn't until she switched insurance companies and got a call from one of the nurses on staff that she finally got to the root of her problem: "She asked a couple of questions that acted as a trigger for me to evaluate my sex drive and realize what was wrong." Health.com: Why women need to worry about heart attacks

Even though sexual problems are among the most commonly reported side effects from blood-pressure drugs, they have not been well publicized and patients may not realize that their prescriptions are to blame. If you suspect that your heart medications are interfering with your sex life, explain the problem to your doctor and ask about alternative medications. Men may be able to counteract the problem with an ED drug such as Viagra. While they can be potentially fatal when taken with nitrates, ED drugs can be safely combined with many heart medications.

Why can't I get in the mood?

Medications can dampen your sex drive, but psychological factors might also be at play. For one thing, sexual dysfunction is a common psychosomatic side effect of medication (sometimes called a "nocebo effect"). But the emotional strain that accompanies heart disease can also impact your sex life. After a cardiac episode, many patients find that any activity in the bedroom leaves them paralyzed with anxiety. "After a heart attack, not only are you physically weak, but you're scared that something might happen during sex," says Chapunoff.

Saldana is gearing up to have open-heart surgery in the near future. She and her husband of 15 years are sexually active about twice a month, but each time she's terrified that she'll have a heart attack. "I experience a lot of chest pains and when things get heated, I can't have him on top of me," she explains. "I haven't shared my fear with my husband, but I'm afraid to lose control for even a moment because it feels like he's crushing my chest."

And then there's the possible role of depression. Research suggests that heart disease and depression are closely related; depression is roughly three times more prevalent among heart attack survivors than in the general population. But depression is also independently associated with sexual dysfunction (including loss of libido and ED), which suggests that, for heart patients, both their bodies and their minds may be affecting their sex lives.

Sexual dysfunction that appears to be caused by a heart problem may also be a sign of an underlying emotional issue, according to Chapunoff. "Heart disease can become the scapegoat," he says.

"People might say, 'I had a heart attack six months ago, so I can't have sex now,' when really it could be unhappiness that they fail to recognize."

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All About Heart Attacks • Sexual and Reproductive Health • Men's Health • Women's Health