Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial.

BACKGROUND: Sexual concerns and changes in sexual activity are common among patients and their intimate partners after an implantable cardioverter defibrillator (ICD). AIMS: Our aims were to (i) describe patient and partner sexual activity and related concerns from the time of an initial ICD implant through 12-month follow-up and (ii) identify factors predictive of return to sexual activity and fears associated with sexual activity. METHODS: This secondary descriptive analysis was conducted with data from a randomized controlled trial (2009-2015) designed to compare 2 interventions for patients (Patient-Only) and for patients and their partners (Patient+Partner) after implant of an initial ICD. The sample included 105 patients and their intimate partners who reported sexual activity during the 24 months before ICD implant. OUTCOMES: The Sexual Concerns Inventory was used to assess sexual activity and related concerns. RESULTS: Study participants comprised 72% male and were of mean age 65.6 ± 10.6 years; partners comprised 64% female and were of mean age 63 ± 11.6 years. Sexual activity increased after ICD: 73% of patients reported no sexual intercourse during 2 months before study enrollment, whereas only 46% reported no sexual intercourse during the 2 months before 12-month follow-up. Reductions in sexual concerns were evident 1 month after implant, with continued reductions through 12 months (patient 6.48 ± 4.03 to 5.22 ± 3.38, P = .004; partner 6.93 ± 4.01 to 5.2 ± 3.56, P < .001). Patient physical health predicted sexual activity 3 months after implant placement (P = .04); general ICD concerns (P < .001) predicted patient ICD-related sexual fears at 3 months. At 12 months, baseline general ICD concerns (P < .02) predicted sexual fears. CLINICAL IMPLICATIONS: ICD patients and partners report low levels of sexual activity at the time of initial ICD implant, with reported increases in sexual activity over the 12-month recovery period: Sexual concerns were highest immediately after ICD implant. STRENGTHS & LIMITATIONS: Notably, the major strengths of this study were the repeated measures and longitudinal study design; the main limitation of the study was the lack of a "usual care" control group. CONCLUSION: Sexual activity at the time of an initial ICD implant is low, and sexual concerns are most prominent for both patients and partners immediately after implant placement. Baseline physical health predicts subsequent sexual activity at 3 months, while general ICD-related worry predicts sexual fears at 3 and 12 months. Streur MM, Rosman LA, Sears SF, et al. Patient and Partner Sexual Concerns During the First Year After an Implantable Cardioverter Defibrillator: A Secondary Analysis of the P+P Randomized Clinical Trial. J Sex Med 2020;17:892-902.

The Influence of Comorbidities, Risk Factors, and Medications on Sexual Activity in Individuals Aged 40 to 59 Years With and Without Cardiac Conditions: US National Health and Nutrition Examination Survey, 2011 to 2012.

BACKGROUND: Sexual activity is increasingly recognized as an important aspect of quality of life for many individuals with cardiovascular disease, although less is known about the factors contributing to sexual functioning in younger adults. OBJECTIVE: This study examined factors influencing sexual activity in individuals aged 40 to 59 years, comparing those reporting a cardiac condition with those without a cardiac condition, in a national population-based sample. METHODS: The data were derived from the 2011 to 2012 National Health and Nutrition Examination Survey, a publicly available data set with a noninstitutionalized nationally representative sample. The sample included individuals between the ages of 40 and 59 years (N = 1741) who completed relevant items related to cardiovascular disease, cardiovascular risk factors, comorbidities, cardiac symptoms, sexual activity, and medication use. Recommended weighting was applied, and the data were analyzed using χ and logistic regression. RESULTS: Overall, 94% of the sample reported sexual activity, although those with coronary artery disease, angina, and myocardial infarction engaged in significantly less sexual activity. Individuals who smoked; had a weight problem, depression, or lung problems; or experienced symptoms of shortness of breath or chest pain with exertion reported less sexual activity. Medications negatively affecting sexual function were central α agonists, potassium sparing diuretics, and antilipidemic agents. Predictors of less sexual activity were smoking, chest pain walking uphill, and weight problems. Unexpectedly more reported, sexual activity was predicted by one or more cardiac conditions. CONCLUSION: In men and women ages 40 to 59 years, certain cardiac conditions, risk factors, comorbidities, symptoms, and medications negatively affected sexual activity, illustrating the need for sexual assessment and counseling to support sexual quality of life.

Depression, Quality of Life, Physical Activity, and the Impact of Drugs on Sexual Activity in a Population-Based Sample, Ages 20-59 Years.

Sexual quality of life is important for many individuals; therefore, this study examined the frequency of depression in a younger and middle-aged population-based sample, and the impact on physical activity, quality of life, and sexual activity, and the role of antidepressant and cardiac drugs on sexual function. The sample, ages 20 to 59 years, completed relevant items for depression, sexual activity, physical activity, quality of life, and drugs. Data were analyzed using descriptive statistics, Pearson correlations, t-tests, and analysis of variance. Those sexually active had lower mean depression scores and higher ratings of quality of life, while those sexually inactive had greater depression and took more drugs. Thorough assessment of drugs, depression, cardiac and other medical conditions, and interest and engagement in sexual activity should be routinely assessed in all patients, regardless of age.

Determinants of sexual function and dysfunction in men and women with stroke: A systematic review.

AIM: The aim of this systematic review was to examine determinants of sexual function and dysfunction in men and women poststroke, and to evaluate effectiveness of interventions. METHODS: A systematic review was conducted using the databases of PubMed, Medline, CINAHL, Cochrane, and Psychinfo, for studies published between January, 2000 and October, 2016. Included were original research, adult ≥18 years, English language, and experimental and non-experimental designs. Excluded were studies of stroke caused by sexual activity, stroke triggered unusual behaviours, and changes in sexual orientation. Studies were evaluated for quality using The Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. Of 19 studies reviewed, 13 were descriptive, three case-controlled and three intervention/randomised controlled trials (RCTs) designs. RESULTS: Participants across studies were predominantly men (90%), with moderate erectile dysfunction (ED), and mild depression. Changes in sexual activity, sexual dissatisfaction and sexual dysfunction were common, including decreased libido, orgasmic problems and ED, significantly worse from pre to poststroke. Results for side of hemiparesis and sexual dysfunction were inconclusive. Sexual rehabilitation interventions differed, but resulted in improved sexual satisfaction, sexual activity frequency and erectile function in two studies. CONCLUSIONS: Sexual dysfunction commonly occurred poststroke, continuing for months or as long as 2 years. Intervention studies were limited, with only two RCTs, thus, firm conclusions cannot be made. Few studies included women or younger stroke patients, indicating the need for further RCTs with larger and more diverse samples.

Sexual counselling for sexual problems in patients with cardiovascular disease.

BACKGROUND: Sexual problems are common among people with cardiovascular disease. Although clinical guidelines recommend sexual counselling for patients and their partners, there is little evidence on its effectiveness. OBJECTIVES: To evaluate the effectiveness of sexual counselling interventions (in comparison to usual care) on sexuality-related outcomes in patients with cardiovascular disease and their partners. SEARCH METHODS: We searched CENTRAL, MEDLINE, EMBASE, and three other databases up to 2 March 2015 and two trials registers up to 3 February 2016. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs, including individual and cluster RCTs. We included studies that compared any intervention to counsel adult cardiac patients about sexual problems with usual care. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included three trials with 381 participants. We were unable to pool the data from the included studies due to the differences in interventions used; therefore we synthesised the trial findings narratively.Two trials were conducted in the USA and one was undertaken in Israel. All trials included participants who were admitted to hospital with myocardial infarction (MI), and one trial also included participants who had undergone coronary artery bypass grafting. All trials followed up participants for a minimum of three months post-intervention; the longest follow-up timepoint was five months.One trial (N = 92) tested an intensive (total five hours) psychotherapeutic sexual counselling intervention delivered by a sexual therapist. One trial (N = 115) used a 15-minute educational video plus written material on resuming sexual activity following a MI. One trial (N = 174) tested the addition of a component that focused on resumption of sexual activity following a MI within a hospital cardiac rehabilitation programme.The quality of the evidence for all outcomes was very low.None of the included studies reported any outcomes from partners.Two trials reported sexual function. One trial compared intervention and control groups on 12 separate sexual function subscales and used a repeated measures analysis of variance (ANOVA) test. They reported statistically significant differences in favour of the intervention. One trial compared intervention and control groups using a repeated measures analysis of covariance (ANCOVA), and concluded: "There were no significant differences between the two groups [for sexual function] at any of the time points".Two trials reported sexual satisfaction. In one trial, the authors compared sexual satisfaction between intervention and control and used a repeated measured ANOVA; they reported "differences were reported in favour of the intervention". One trial compared intervention and control with a repeated measures ANCOVA and reported: "There were no significant differences between the two groups [for sexual satisfaction] at any of the timepoints".All three included trials reported the number of patients returning to sexual activity following MI. One trial found some evidence of an effect of sexual counselling on reported rate of return to sexual activity (yes/no) at four months after completion of the intervention (relative risk (RR) 1.71, 95% confidence interval (CI) 1.26 to 2.32; one trial, 92 participants, very low quality of evidence). Two trials found no evidence of an effect of sexual counselling on rate of return to sexual activity at 12 week (RR 1.01, 95% CI 0.94 to 1.09; one trial, 127 participants, very low quality of evidence) and three month follow-up (RR 0.98, 95% CI 0.88 to 1.10; one trial, 115 participants, very low quality of evidence).Two trials reported psychological well-being. In one trial, no scores were reported, but the trial authors stated: "No treatment effects were observed on state anxiety as measured in three points in time". In the other trial no scores were reported but, based on results of a repeated measures ANCOVA to compare intervention and control groups, the trial authors stated: "The experimental group had significantly greater anxiety at one month post MI". They also reported: "There were no significant differences between the two groups [for anxiety] at any other time points".One trial reporting relationship satisfaction and one trial reporting quality of life found no differences between intervention and control.No trial reported on satisfaction in how sexual issues were addressed in cardiac rehabilitation services. AUTHORS' CONCLUSIONS: We found no high quality evidence to support the effectiveness of sexual counselling for sexual problems in patients with cardiovascular disease. There is a clear need for robust, methodologically rigorous, adequately powered RCTs to test the effectiveness of sexual counselling interventions for people with cardiovascular disease and their partners.

Sexual concerns of cardiac patients: A psychometric analysis.

The primary aim of this study was to evaluate the psychometric properties of the Steinke Sexual Concerns Inventory-General Cardiac Version (SSCI-GCV) and to examine its use across multiple cardiac diagnoses. A sub-analysis of a cross-sectional sample of 205 cardiac patients from the central USA was completed. Our analyses yielded promising evidence that the SSCI-GCV is a reliable (Cronbach's alpha = 0.86) and valid measure of sexual concerns and supported three subscales for this 11-item instrument. Further means testing suggested that participants with a diagnosis of stroke or kidney disease reported more sexual concerns than those without such diagnoses, but differences were not found for any specific cardiac health problem or intervention. These findings support the use of the SSCI-GCV as a brief and easily administered instrument that can be used to broadly assess sexual concerns in cardiac populations and to inform sexual counselling of cardiac patients in practice.

Change in sexual activity after a cardiac event: the role of medications, comorbidity, and psychosocial factors.

AIM: The aim of this study was to examine change in sexual activity before and after cardiac diagnosis in men and women by medication class. BACKGROUND: Decline in sexual activity after cardiac diagnosis frequently occurs, with adverse effects of medications believed to play a role, although literature by subclass of drugs are conflicting. METHODS: Mixed methods approach was used to evaluate cardiac patients' (N=211) self-reported medications and changes in sexual activity before and after cardiac diagnosis via mailed survey. Chi square, logistic regression, and thematic analysis were used. RESULTS: First and third generation beta blockers, class 1 calcium channel blockers, vasodilators, diuretics, and loop diuretics adversely affected sexual activity. Significant predictors of change in sexual activity were number of medications, education level, and income; the overall model predicted 25.7% of the variance in sexual activity. CONCLUSIONS: Sexual assessment and discussion of sexual concerns and side effects of medications by nurses are important to support sexual function.

Sexual counselling for individuals with cardiovascular disease and their partners: a consensus document from the American Heart Association and the ESC Council on Cardiovascular Nursing and Allied Professions (CCNAP).

After a cardiovascular event, patients and their families often cope with numerous changes in their lives, including dealing with consequences of the disease or its treatment on their daily lives and functioning. Coping poorly with both physical and psychological challenges may lead to impaired quality of life. Sexuality is one aspect of quality of life that is important for many patients and partners that may be adversely affected by a cardiac event. The World Health Organization defines sexual health as '… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences ….'(1(p4)) The safety and timing of return to sexual activity after a cardiac event have been well addressed in an American Heart Association scientific statement, and decreased sexual activity among cardiac patients is frequently reported.(2) Rates of erectile dysfunction (ED) among men with cardiovascular disease (CVD) are twice as high as those in the general population, with similar rates of sexual dysfunction in females with CVD.(3) ED and vaginal dryness may also be presenting signs of heart disease and may appear 1-3 years before the onset of angina pectoris. Estimates reflect that only a small percentage of those with sexual dysfunction seek medical care;(4) therefore, routine assessment of sexual problems and sexual counselling may be of benefit as part of effective management by physicians, nurses, and other healthcare providers.

Perceptions of intimate relationships in partners before and after a patient's myocardial infarction.

AIMS AND OBJECTIVES: To describe and explore how partners rate their intimate relationship before and after the patients' first myocardial infarction. A further aim was to investigate the association between partners' rating of their intimate relationship and self-rated health. BACKGROUND: To date, information on how partners experience the intimate relationship before and after a patient's myocardial infarction is sparse. DESIGN: A descriptive and exploratory design with longitudinal data collection. METHODS: The study comprised 127 partners, aged 34-87 years. Data collection included self-reported information on socio-demographic data, intimate relationship and self-rated health one year before and one year after patients' first myocardial infarction. Intimate relationship was assessed by the Swedish version of the Relationship Assessment Scale. Self-rated health was evaluated by the EuroQoL visual analogue scale. RESULTS: In general, partners reported high satisfaction with their intimate relationship both before and after the patients' myocardial infarction. Women reported somewhat lower ratings in their intimate relationship than men before the myocardial infarction. Women increased their ratings after one year, while men on average decreased their ratings. Partners with higher education reported lower ratings for intimate relationship after one year. Those with children living at home rated intimate relationship lower than those without children living at home after one year. Partners' self-rated health status was stable over time. No significant association between intimate relationship and self-rated health was found. CONCLUSIONS: This study provides important insights regarding couples' relationships from the perspective of the partner. Socio-demographic factors such as sex, educational level, having children living at home and employment status may influence how the relationship, from the partners' perspective, is affected by a myocardial infarction event. RELEVANCE TO CLINICAL PRACTICE: This study provides insight into how partners rate their intimate relationship and self-rated health over time before and after patients' myocardial infarction.

How can heart failure patients and their partners be counseled on sexual activity?

Sexual intimacy is part of a healthy relationship and is often reflected in overall quality of life and satisfaction. There are many psychological, physical, and medical components that influence sexual activity in heart failure (HF), and patients and partners alike often have sexual concerns and misconceptions. This article addresses what is known about sexual concerns and sexual dysfunction from a variety of perspectives, and provides guidance for health care providers on the essential elements of sexual counseling for those with HF.

Sexuality and chronic illness.

Sexual function is often affected in individuals living with chronic illness and their partners, and multiple comorbidities increase the likelihood of sexual dysfunction. This review focuses on the areas of cardiovascular disease, respiratory conditions, and cancer, all areas for which there are practical, evidence-based strategies to guide sexual counseling. Although nurses have been reluctant to address the topic of sexuality in practice, a growing number of studies suggest that patients want nurses to address their concerns and provide resources to them. Thus, nurses must be proactive in initiating conversations on sexual issues to fill this gap in practice.

Sexual dysfunction in women with cardiovascular disease: what do we know?

The problem of sexual dysfunction in cardiovascular disease has received attention in both professional and lay literature, particularly for men. There is only beginning awareness of the problem of sexual dysfunction in women in general and for those with cardiovascular disease. This evidence-based review focuses on the problem of sexual dysfunction in women in the general population compared with those women with cardiovascular disease. The underlying mechanisms of female sexual dysfunction are addressed, along with what is known about female sexual dysfunction in those with coronary artery disease, hypertension, and heart failure. The assessment and management of female sexual dysfunction in the presence of cardiovascular disease are addressed, although the strategies for management are controversial and evidence is lacking in some cases. Nurses can play a key role in initiating discussion with women related to sexual dysfunction and assisting them in finding appropriate resources and treatment.

Sexual problems in cardiac patients: how to assess, when to refer.

It is increasingly realized that discussing sexuality is an important issue in the holistic care for cardiac patients. In this review article, the conditions of a good assessment of sexual problems are identified such as creating an appropriate environment, ensuring confidentiality, and using appropriate language. Second, we present different styles and approaches that can be used to start the assessment, differing between settings, persons, or disciplines. The PLISSIT (permission, limited information, specific suggestion, and intensive therapy) model can be helpful to initiate discussion about sexuality with the cardiac patient and his/her partner. This model is a stepwise approach using various levels of discussion or treatment. Open-ended question can facilitate discussion about sexual concerns, and validated questionnaires or diaries can be used to assess sexual problems. Patients with sexual concerns and problems should be counseled and/or treated appropriately, and adequate follow-up is needed. Additional training and research are needed to further improve the quality of sexual assessment and counseling in cardiac patients.

Risk Factors, Depression, and Drugs Influencing Sexual Activity in Individuals With and Without Stroke.

PURPOSE: The aim of the study was to analyze factors affecting sexual activity in individuals with and without stroke, ages 40-59 years, in a national, cross-sectional, population-based sample derived from the National Health and Nutrition Examination Survey (NHANES). DESIGN: Descriptive, cross-sectional survey. METHODS: Data were obtained from the NHANES (2011-2012) data set from individuals (N = 3,649) completing items related to cardiovascular risk factors, drugs, and sexual activity. Data were analyzed using chi-square, t tests, and logistic regression. FINDINGS: Overall, number of drugs, smoking, and depression significantly predicted sexual activity. When comparing sexually active to not sexually active, those with stroke had significantly less sexual activity (t = 2.822, p = .005) and reduced sexual activity per week or month (χ = 16.275, p = .005, df = 4). Those taking angiotensin-converting enzyme inhibitors and statins had reduced sexual activity. CONCLUSIONS/CLINICAL RELEVANCE: Findings illustrate the importance of risk factor modification and nurses engaging in sexual assessment, education, and counseling to support sexual quality of life in younger individuals with stroke.

Using extended theory of planned behavior to determine factors associated with help-seeking behavior of sexual problems in women with heart failure: a longitudinal study.

Introduction: This study used extended theory of planned behavior (extended TPB) to understand the underlying factors related to help-seeking behavior for sexual problems among Iranian women with heart failure (HF).Methods: We recruited 758 women (mean age = 61.21 ± 8.92) with HF at three university-affiliated heart centers in Iran. Attitude, subjective norms, perceived behavioral control, behavioral intention, self-stigma of seeking help, perceived barriers, frequency of planning, help-seeking behavior, and sexual function were assessed at baseline. Sexual function was assessed again after 18 months. Structural equation modeling was used to explain change in sexual functioning after 18 months.Results: Attitude and perceived behavioral control were positively correlated to behavioral intention. Behavioral intention was negatively and self-stigma in seeking help was positively correlated to perceived barriers. Behavioral intention was positively and self-stigma in seeking help was negatively correlated to frequency of planning. Perceived behavioral control, behavior intention, and frequency of planning were positively and self-stigma in seeking help and perceived barriers were negatively correlated to help-seeking behavior. Help-seeking behavior was positive correlated to the change of FSFI latent score.Conclusions: The extended TPB could be used by healthcare professionals to design an appropriate program to treat sexual dysfunction in women with HF.

Trends in sexual concerns after myocardial infarction.

BACKGROUND AND RESEARCH OBJECTIVE: Healthcare providers are expected to provide information and support as myocardial infarction (MI) patients resume normal activities, including sexual relations. The healthcare literature, however, suggests that few providers follow through with the assessment of understanding, provision of appropriate information, and support for patients with MI in resuming their sexual activity. The purpose of the study was to examine trends in sexual concerns of patients with MI and patterns of sexual concerns in early, middle, and later recovery periods. SAMPLE AND METHODS: Archival data were analyzed using thematic content analysis. Narrative comments from 3 samples of patients with MI spanning the time periods of 1995 to 2002 (N = 302) were unitized into sentences and phrases. A total of 346 units of analysis were coded using the concept of sexual integrity and examined across time: (a) sexual concerns from 1995 to 2002 and (b) sexual concerns in early, middle, and later recovery after MI. FINDINGS AND CONCLUSIONS: Predominant themes included alterations in self-identity, specifically physical and psychological health state. Communication issues involved a lack of sexual information and intimacy concerns. Perception of patients with MI on family concerns, particularly the influence of spouses upon return to sexual activity, was reflected within the comments. Trends in early, middle, and later recovery periods were similar to findings across the 8-year period. All 3 determinants of sexual integrity were represented in the data. Our findings clearly illustrate the need for sexual counseling for patients with MI by healthcare professionals and help to inform providers about content for patient education.

Decreased sexual function in partners after patients' first-time myocardial infarction.

BACKGROUND: A myocardial infarction event affects not only patients but also partners, although how it affects the partners' sexual function is not studied. AIM: The purpose of this study was to describe and compare how partners experienced their sexual function one year before with one year after first-time myocardial infarction of their partner. METHODS: A longitudinal and comparative design was used. Self-reported data on Watts Sexual Function Questionnaire was collected retrospectively at two occasions from 123 partners (87 women and 36 men), measuring the year prior to the first-time myocardial infarction and the year after. Data were analysed using descriptive and inferential statistics. RESULTS: The total score for Watts Sexual Function Questionnaire showed a significant decrease over time. In all four subscales a decrease was found, which were statistically significant in three out of the four subscales (sexual desire, 19.39 vs 18.61; p<0.001, orgasm, 14.11 vs 13.64; p=0.027 and satisfaction, 12.61 vs 12.31; p=0.042). Twenty-six partners reported that their intercourse frequencies decreased over time, while six partners reported an increased intercourse frequency. CONCLUSIONS: Partners' sexual function decreased after patients' first-time myocardial infarction. It is important for health personnel to offer information and discussion about sexual function and concerns with both patients and partners after a first-time myocardial infarction.