1. Jaarsma, Tiny PhD RN

Article Content

Cardiac patients may experience sexual problems as a result of their disease or the medical treatment or due to patient or partner fear or uncertainty. Nurses can ensure that questions and concerns are addressed through patient education. But, do we have enough guidance in nursing to fulfill this role? A rough PubMed search will find more than 1,500 hits when using the keywords "sexual" and "cardiac"; "sexual function" and "cardiac" will find more than 800 articles, and if we add "nursing," a total of 74 articles remain.


Although an increasing number of studies address sexual problems in cardiac patients and possible interventions to improve return to sexual activity, it is still not easy to find specific guidance for teaching and treatment. To illustrate, in the 3 major heart failure (HF) guidelines by large professional organizations (ie, the American College of Cardiology/American Heart Association, European Society of Cardiology, and the Heart Failure Society of America [HFSA]),1-3 the topic of sexuality is addressed, but the advice given is general. It is recognized that sexual problems are prevalent in HF patients and that these problems adversely affect their quality of life and well-being and that of their partners. We therefore would expect that this is addressed in guidelines of HF management. In the recently updated American College of Cardiology/American Heart Association 2009 guidelines, possible sexual problems are merely discussed in the context of erectile dysfunction and the prescription of a phosphodiesterase type 5 inhibitor (eg, sildenafil).1 This guideline states that limited data exist on the efficacy and safety of phosphodiesterase type 5 inhibitors. Although HF patients with HF appear to tolerate short-term administration of the drug without difficulty, sildenafil should not be given to patients taking nitrates.1


Another important recently published guideline addressing the management of HF patients is the guideline from the European Society Cardiology.2 This guideline also discusses the use of phosphodiesterase type 5 inhibitors to reduce pulmonary pressures but does not recommend them for patients with advanced HF. The European Society Cardiology guideline also lists "sexual activity" as one of the educational topics and recommend that patients should be reassured about engaging in sex and discuss problems with healthcare professionals. They also advise that patients need to understand specific sexual problems and various coping strategies. Curiously enough, these guidelines mention that although there is limited evidence regarding the influence of sexual activity on clinical status, a slightly increased risk of decompensation triggered by sexual activity in patients in New York Heart Association class III-IV has been reported. In the same guideline, it is stated that cardiovascular symptoms such as dyspnea, palpitations, or angina during sex rarely occur in patients who do not experience similar symptoms during exercise levels representing moderate exertion. For practitioners who need to concretely give the actual advice to patients and partners, these general statements fail to provide sufficient information.


Finally, the guidelines of the HFSA also stress the impact of HF on the quality of life of patients and families, stating that HF can affect employment, relationships, leisure activities, eating, sleeping, and sexual activity.3 These guidelines state that patients may be reluctant to initiate discussion regarding sexuality, may be unaware of treatment options, and may be intentionally nonadherent to HF medications to determine their influence on sexual dysfunction. The HFSA guidelines recommend that treatment options for sexual dysfunction need to be discussed openly with both male and female patients with HF.


Although the importance of recognizing sexual problems and the need for education and counseling are stressed in the most recent guidelines, it still is not easy for practitioners to find concrete guidance on how to assess, how to refer, or how to address sexual activity in daily practice. More concrete guidance is needed to improve practice. This issue of the Journal of Cardiovascular Nursing includes 2 articles addressing sexuality in cardiac patients. One article specifically addresses sexual concerns of female cardiac patients, and the other article discusses approaches that can be used to address sexuality in cardiac patients and which questions and instruments can be used in research and practice to assess sexual problems.4,5 With these articles, the authors discuss the need for more concrete information about the return to sexual activity. This information needs to be added to existing guidelines.




1. Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults. A report of the ACC Foundation/AHA task force on practice guidelines developed in collaboration with the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. 2009;53:e1-e90. [Context Link]


2. Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the task force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Eur J Heart Fail. 2008;10:933-989. [Context Link]


3. Heart Failure Society of America. Executive summary: HFSA 2006 comprehensive heart failure practice guideline. J Card Fail. 2006;12:10-38. [Context Link]


4. Jaarsma T, Steinke EE, Gianotten W. Sexual problems in cardiac patients: how to assess, when to refer. J Cardiovasc Nurs. 2010;25(2):159-164. [Context Link]


5. Steinke EE. Sexual dysfunction in women with cardiovascular disease: what do we know? J Cardiovasc Nurs. 2010;25(2):151-158. [Context Link]