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CLINICAL STATEMENTS AND GUIDELINES

August 29, 2023 Circulation. 2023;148:e9–e119. DOI: 10.1161/CIR.0000000000001168

Virani et al 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Chronic Coronary Disease Guideline

clinical trial, data are insufficient to recommend alcohol for cardioprotection.11 In fact, a recent genetic analysis found that the causal association between light-to-moderate levels of alcohol intake and lower CVD risk are likely mediated by confounding lifestyle factors.8 In patients with CCD, excessive alcohol is linked to hypertension, increased mortality rate, and recurrent cardiovascular events. PRIME (Prospective Epidemiological Study of Myocardial Infarction) found that binge drinking (>50 g at least once a week) was associated with a higher risk of coronary events (hazard ratio, 2.03 [95% CI, 1.41-2.94]) compared with regular drinking.10 In the Determinants of Myocardial Infarction Onset Study across 45 community and tertiary-care medical centers, binge drinking was associated with a 2-fold higher mortality rate after an acute MI.9 The Global Burden of Disease 2016 analysis confirmed a J-shaped relationship with alcohol and outcomes, but the benefit appeared to be offset by increasing cancer risks, concluding that the level of alcohol consumption that minimized harm was zero.19 Therefore, patients who do not drink alcohol or who have a medical reason to avoid alcohol (eg, liver dysfunction, drug-drug interactions) should not be encouraged to drink alcohol for the purposes of cardiovascular protection. Clinicians should further counsel their patients against binge drinking.

4.2.5 Sexual Health and Activity

Recommendations for Sexual Health and Activity Referenced studies that support the recommendations are summarized in the Online Data Supplement. COR LOE Recommendations

2a B-NR 1 In patients with CCD, it is reasonable to individual-

ize resumption of sexual activity based on type of sexual activity, exercise capacity, and postprocedural healing.*1,2

2a B-NR 2 In patients with CCD, cardiac rehabilitation and

regular exercise can be useful to reduce the risk of cardiovascular complications with sexual activity.*3

3: Harm B-NR 3 In patients with CCD, phosphodiesterase type 5 inhibi-

tors should not be used concomitantly with nitrate medications because of risk for severe hypotension.*4

*Modified from the 2012 AHA Scientific Statement on Sexual Activity and Cardiovascular Disease.5

Synopsis Sexual health is important to QOL. Sexual activity represents moderate physical activity at around 3 to 5 metabolic equivalents.5 If a patient with CCD can reach this level during exercise testing without ischemia or symptoms, then the risk for ischemia during sexual activity is low, especially considering the short exposure period.2 It is rare for a patient to die from cardiac disease dur- ing sexual intercourse; in this regard, men appear more at risk than women,6 with the absolute rate being very small. Sexual activity is associated with 1% of all MIs.3 Men and women with CCD and its risk factors have a high prevalence of sexual dysfunction.7 Recent MI and coronary artery bypass surgery may additionally compromise sexual function5; in this regard, sexual counselling may be helpful, and resuming sexual activity does not appear to be associated with an increased risk of death. Of particular relevance to patients with CCD is the need to avoid the combined use of nitrates with phosphodiesterase type 5 inhibitors.4

Recommendation-Specific Supportive Text

1 Recommendations after PCI and CABG may

depend on whether femoral or radial access was performed, and whether surgery was performed in a sternal-sparing manner.5,8 The patient should be well compensated, euvolemic, and without significant angina. Patients with CCD who are functionally well compensated or patients with no or mild angina, given the low risk of MI or sudden death, should be considered safe for sexual activity. Sexual activity represents an exercise level of approximately 3 to 5 metabolic equivalents, compared with a typical exercise treadmill test that involves approximately 4 metabolic equivalents. The risk of MI or sudden death resulting from sexual activity is very low. 3 Patients with CCD who want to engage in sexual activity should undergo a medical evaluation, similar to other forms of exercise in the presence of CCD.5 Because sexual activity is associated with increased metabolic requirements, patients with unstable or decompensated CCD should refrain from sexual activity.5

2 In addition to a recommendation for CR incorpo-

rating sexual counseling, in men with CCD, conservative measures such as sexual rehabilitation, consisting of 12 weeks of sexual rehabilitation with physical exercise training, pelvic floor exercise and psychoeducation, was associated with better sexual function by the International Index of Erectile Function.9,10

3 Phosphodiesterase type 5 inhibitors should not be

used concomitantly with nitrate medications, often used to treat CCD, because of the potential for severe hypotension.4 Sildenafil and vardenafil have half-lives of ∼4 hours. Tadalafil is long-acting and has a half-life of 17.5 hours. Patients on sildenafil or vardenafil should avoid taking nitroglycerine for ≥24 hours (≥48 hours for tadalafil).5 In patients on long-acting nitrate therapy who want to use a phosphodiesterase type 5 inhibitor, decision on the use of phosphodiesterase type 5 inhibitor should

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