The impact of sexual therapy on patients after cardiac events participating in a cardiac rehabilitation program

Influence of a cardiac rehabilitation programme on the return to work of workers with ischaemic heart disease: Influence of a cardiac rehabilitation programme

This study aimed to examine the employment status of patients who have experienced ischemic heart disease one year after undergoing cardiac rehabilitation. For this, a quasi-experimental pre-post study without a control group of active workers aged 18 to 65 years diagnosed with ischemic heart disease and included in a cardiac rehabilitation programme was conducted. Sociodemographic and occupational data, cardiovascular risk factors and clinical-therapeutic data on heart disease were collected. A total of 214 patients were included, of which 115 patients returned to work. Several clinical factors contributing to return to work were identified: preserved left-ventricular ejection fraction (≥55%), < 3 obstructed coronary vessels, and stent revascularisation. Socio-occupational factors that may positively influence return to work were identified: age < 50 years, absence of anxious-depressive symptoms, higher level of education, and occupations with low physical strain. Cardiac rehabilitation is effective in improving cardiac function and health-related quality of life in workers with ischemic heart disease. Return to work and duration of temporary incapacity were associated with clinical-therapeutic variables and psycho-socio-occupational factors, such as type of job, physical strain, anxiety and depression, and age of the worker.

Determinants of Sexual Health and Sexual Quality of Life after Cardiovascular Surgeries: An Integrative Review

BACKGROUND AND AIM

Sexual health and sexual quality of life are key components of psychosocial adjustment after cardiac surgeries and are often linked with improving the general quality of life. Reviews have been conducted to highlight the associations between cardiovascular diseases and sexual dysfunctions, but no review reported determinants of sexual health and sexual quality of life in patients after cardiovascular surgeries. We aimed to comprehensively examine the determinants of sexual health and sexual quality of life among individuals with cardiovascular surgeries.

METHODS

Literature was searched within PubMed, CINAHL, Scopus, Web of Science, and OVID databases. In total, 816 records were identified from database searches, 279 records were screened, and 11 empirical studies were included for review. Relevant data were extracted using literature summary tables and synthesised using an inductive approach.

RESULTS

The core determinants of sexual health and sexual quality of life were type of surgery and comorbidities, fears and uncertainties regarding sexual activity, sexual health education and counselling, spousal relationship and communication, and demographic factors such as advanced age and literacy levels. Major surgeries performed were coronary artery bypass grafting (CABG) and heart valve surgeries. The data collection tools used to collect data for sexual health and sexual quality of life were the International Erectile Function Questionnaire (IEFQ), International Index of Erectile Function (IIEF), Female Sexual Function Index (FSFI), Sexual Knowledge CABG Scale (SKS-CABG), Sexual Quality of Life Questionnaire (SQOL), SKS-Myocardial Infarction Scale (SKS-MI), and Couple Communication Scale (CCS).

CONCLUSIONS

Despite their importance, sexual health and quality of life are frequently overlooked during patient rehabilitation after cardiovascular surgeries. The lack of adequate education and counselling from healthcare professionals frequently leads to increased fear and uncertainties among individuals and their partners. Therefore, more person-centred educational and counselling approaches should be developed to address the sexual concerns of individuals and their partners.

Effects of Sexual Rehabilitation on Sexual Dysfunction in Patients with Cardiovascular Disease: A Systematic Review and Meta-Analysis

PURPOSE

Cardiovascular disease (CVD) is one of the leading causes of death, accounting for one-third of all deaths worldwide. Patients with CVD are three times more likely to complain of sexual dysfunction than healthy people. Causes of sexual dysfunction in patients with CVD include physical/mental changes and drug side effects. The prevalence of sexual dysfunction in patients with CVD has been estimated to be up to 89%. Ordinary treatments such as pharmacotherapy cannot effectively reduce sexual problems. Therefore, sexual rehabilitation has a broad spectrum, including exercise therapy such as pelvic floor muscle treatment, appropriate counseling, a multidisciplinary approach, and partner rehabilitation. In this study, systematic review and meta-analysis was performed to investigate the effect of sexual rehabilitation on sexual problems in patients with CVD.

MATERIALS AND METHODS

Comprehensive literature searches were conducted using MEDLINE, Cochrane Library electronic database, and EMBASE through June 2022. Questionnaire scores at the end point as outcomes of the study were recorded as were standardized mean difference (SMD) with their 95% confidence intervals (CIs). Meta-regression analysis was conducted for each moderator. We performed a risk of bias evaluation for included studies using the RoB 2 tool.

RESULTS

The overall SMD in the meta-analysis for sexual rehabilitation versus no-sexual rehabilitation was 0.430 (95% CI, 0.226-0.633). There was a statistical difference between groups. SMD changes were 0.674 (95% CI, 0.308-1.039) at one month and 0.320 (95% CI, 0.074-0.565) at six months. The regression analysis with all variables (number of patients, study duration, and questionnaire types) revealed no significance.

CONCLUSIONS

This study indicates that sexual rehabilitation is an effective method with high therapeutic potential for sexual dysfunction of patients with CVD. However, for clinical application, well-designed studies with many patients should be conducted in the future and the standardization of rehabilitation protocols is required.

Sexual Activity After Myocardial Revascularization Surgery

After a cardiovascular event, patients and their families often face numerous changes in their lives. Poorly addressing physical and psychological challenges can lead to an impaired quality of life. Sexuality is an important quality of life aspect to many patients and couples who can be negatively affected by a cardiovascular event. Sexual health requires a positive and respectful approach to sexuality and sexual relationships. Time to resume sexual activity after myocardial revascularization surgery is a gap in cardiologic practice. We know from literature that coronary patients have decreased sexual activity. There are barriers from the medical environment such as lack of knowledge, confidence and training, and many others that arise from the patient's perspective, which do not allow generating a space to address sexual problems. This review aims to familiarize and update cardiologists, providing knowledge and resources to face the impact of myocardial revascularization surgery on the quality of sexual life, promoting multidisciplinary management among doctors and other health professionals.

Sexual Activity After Myocardial Revascularization Surgery

After a cardiovascular event, patients and their families often face numerous changes in their lives. Poorly addressing physical and psychological challenges can lead to an impaired quality of life. Sexuality is an aspect of quality of life that is important to many patients and couples who can be negatively affected by a cardiovascular event. Sexual health requires a positive and respectful approach to sexuality and sexual relationships. The timing of return to sexual activity after myocardial revascularization surgery is a gap in cardiology practice. We know from the literature that coronary patients have a decrease in sexual activity. There are barriers from the medical environment such as lack of knowledge, confidence, and training, and many others that arise from the patient's perspective, which do not allow generating a space to address sexual problems. This review aims to familiarize and update the cardiologist, bringing knowledge and resources closer to the impact of myocardial revascularization surgery on the quality of sexual life of patients, always encouraging multidisciplinary management among doctors and other professionals in health.

Factors shaping the provision of sexual health education for adults with acute coronary syndrome: A scoping review

OBJECTIVE

Each year, 63,000 Canadians are diagnosed with acute coronary syndrome (ACS) and 73 % survive. Sexual health education for ACS survivors is recommended but is not routinely provided. A scoping review was performed to inform health care providers about factors shaping sexual health education for ACS survivors.

METHODS

Three databases were searched, 208 studies were screened, and 24 were included in this scoping review. Significant points from the selected studies were charted and synthesized.

RESULTS

This review confirmed absent to limited provision of sexual health education to individuals with ACS. Key factors influencing lack of provision of sexual health were categorized according to macro, meso, and micro levels. At the macro level, societal and cultural factors were noted. The meso level included healthcare environment and limited healthcare provider knowledge. At the micro level, healthcare professional-healthcare consumer relationships and role clarity were noted.

CONCLUSION

A sex positive approach may facilitate provision of sexual health education.

PRACTICE IMPLICATIONS

This scoping review points to the need to use a sex positive lens to identify and remove barriers to facilitate the provision of sexual health education. Providing this education may result in reduced fear, depression, and anxiety in ACS survivors.

[Exercise training and erectile dysfunction in patients after coronary artery bypass grafting]

AIM

to estimate the effects of exercise training on erectile function after coronary artery bypass grafting.

MATERIALS AND METHODS

114 men with stable coronary artery disease undergoing on - pump coronary artery bypass grafting were examined. Patients with ED were randomized into two groups comparable in the main demographic, clinical and baseline parameters: a group of patients undergoing supervised exercise trainings at the outpatient rehabilitation center (n=53) and a group of patients without any exercise trainings at the outpatient hospital (n=61). Patients were assessed 1, 6 and 12 months after CABG. All patients underwent echocardiography (ECHO-CG), bicycle ergometer test without discontinuation of the drug therapy, measurement of nocturnal penile tumescence (NPT), ultrasound assessment of the cavernous arteries with the further estimation of their endothelial function.

RESULTS

In addition to the expected improvements in exercise tolerance, regular cycling exercises led to a significant recovery of erectile function (number and duration of NTP, increased penile blood flow volume, estimated during NTP measurement), improved endothelial function of the cavernous arteries, compared to patients without exercise trainings. However, the obtained effects in the group with exercise trainings were short - term. One year after CABG, the number of NTP and penile blood flow volume were superior in patients undergoing exercise trainings. Differences in other parameters became less reliable between the groups.

CONCLUSION

Aerobic exercise trainings appeared to be effective for optimizing exercise tolerance, erectile and endothelial function, and allow improving the prognosis of these patients and, therefore, are needed to be included in the rehabilitation programs for patients undergoing CABG.

A place of understanding: Patients' lived experiences of participating in a sexual rehabilitation programme after heart disease

AIMS AND OBJECTIVES

The aim of this project was to explore the lived experience of participating in a nonpharmacological sexual rehabilitation programme.

BACKGROUND

In the healthcare system, patients are important stakeholders, and their experience and knowledge are essential to include when evaluating rehabilitation programmes. Patient experiences with participating in sexual rehabilitation for cardiovascular patients have not yet been investigated.

METHODS

Ten qualitative interviews were conducted with male patients from a randomised controlled trial investigating the effect of a 12-week rehabilitation programme focusing on sexuality. The analysis was inspired by Paul Ricoeur's theory of interpretation. Analysis consisted of three levels: (i) naive reading, (ii) structural analysis and (iii) critical interpretation and discussion. The theoretical framework reflects aspects of behavioural theory of social cognitive theory developed by Albert Bandura and his concept of self-efficacy.

RESULTS

The findings are presented as themes extracted from the structural analysis and interpreted in the critical interpretation and express the way in which cardiovascular patients experience participating in a sexual rehabilitation programme. Three themes were identified reflecting the intervention to be a special place of understanding, describing the intervention as a supporting atmosphere and finally expressing the intervention as empowering sexuality.

CONCLUSIONS

Participating in the sexual rehabilitation programme was experienced as efficient, valuable, motivating and safe, but dependent on a professional setting. The intervention developed participants' self-efficacy with regard to their sexual performance and relationship.

RELEVANCE TO CLINICAL PRACTICE

The findings highlight the importance of a professional setting including certain competencies such as humour and professional skills when handling the after-care of cardiovascular patients with sexual problems.

Effect of Sexual Rehabilitation Program on Anxiety, Stress, Depression and Sexual Function among Men with Coronary Artery Disease

Background: Patients with coronary artery disease suffer from diminished sexual activity leading to anxiety, stress, and depression. Sexual rehabilitation is the key to the care and treatment process of such patients. Purpose: The present study aimed to examine the effect of sexual rehabilitation program on anxiety, stress, depression and sexual function in men with coronary artery disease. Methods: This was a clinical trial study conducted on 80 male patients suffering from coronary artery disease referred to CCU (Coronary Care Unit) wards in Kerman, Iran. Sample was randomly assigned into two intervention and control groups. The intervention consisted of the sexual rehabilitation program which included two components of education and exercise. Using IIEF (International Index of Erectile Function) and DASS21 (Depression, Anxiety, Stress Scale) anxiety, stress, depression and sexual function have been examined before and one-month after intervention in the two groups. The collected data were analyzed with SPSS version 19 (IBM, Armonk, New York), using descriptive and inferential statistics (such as Pearson correlation coefficient, independent t test, and analysis of variance). Results: Result showed that the intervention group had significantly lower mean scores in anxiety, stress, depression and sexual function compared to the control group (p < 0.0001). Conclusion: According to the results, sexual rehabilitation reduced anxiety, stress, and depression and improved sexual function among men with coronary artery disease. Therefore, it is recommended sexual rehabilitation be an integral part of cardiac rehabilitation.

Sexual Activity in Patients with Cardiac Diseases

SUMMARY – In this article, we outline the latest guidelines published by the American Heart Association on sexual activity in patients with coronary artery disease, heart failure, structural heart diseases, arrhythmias, implanted pacemakers or cardioverter defibrillators, as well as on treatment options of sexual dysfunction. Sexual activities are similar to mild/moderate physical activity during a short period. Most patients are recommended to involve in sexual activity after prior comprehensive evaluation of physical condition. Those with stable cardiac symptoms and good functional capacity are at a low risk of adverse cardiovascular events, and others require treatment or stabilization before involving in sexual activity. Stress testing is useful in evaluating safety of sexual activity in patients with questionable or undetermined risk. Treatment of sexual dysfunction includes counseling of patients and their sexual partners, and drug treatment with phosphodiesterase inhibitors (sildenafil, tadalafil, vardenafil) which have been demonstrated to be safe and effective, in men, and with serotonin reuptake inhibitors (flibanserin) and local vaginal estrogen administration in women. In conclusion, in routine clinical practice, patients should be approached individually and multidisciplinarily in order to detect and eliminate the factors that interfere with normal sexual activities and disturb the quality of life.

Women's Sexual Issues After Myocardial Infarction: A Literature Review

BACKGROUND

Sexual activity after myocardial infarction (MI) is a concern for patients and often a challenge for health care professionals to address. It is widely recognized that most patients, of both sexes, report sexual problems or concerns after MI. However, there are reported differences between men and women. Women with sexual concerns may seek less help from health care providers and are more inclined to conceal them because of cultural barriers.

OBJECTIVE

The aim of the current study is to present a comprehensive review of the literature describing women's sexual issues after MI.

METHOD

A systematic search of the relevant literature was performed within international databases, including PubMed/Medline, Scopus, ScienceDirect, and ProQuest, as well as Google Scholar using relevant keywords. Also, Persian electronic databases such as Magiran, Scientific Information Databases, and Iran Medex were searched from the inception to October 2014. Articles focusing on the sexual issues after MI only in women, as well as articles on both sexes where women's results could be separated, were included in this review.

RESULTS

A total of 8 articles were included in the final dataset. The main themes of women's sexual concerns after MI were "loss or decrease of sexual activity," "dissatisfaction of sexual relationship," "doubt about resumption time of sexual activity," "fear of reinfarction or sudden death during sexual activity after MI," "knowledge deficit regarding sexual activity after MI," and "poor performance of health care providers in sexual counseling."

DISCUSSION

The results of this review demonstrate that women's post-MI sexual activity is affected by many concerns. The concerns may be a knowledge deficit related to not receiving necessary consultation on this topic. Nurses, as first-line care givers, can provide appropriate consultation and education for patients post-MI. As a result, breaking taboo imposed by cultural barriers, personal assumptions, or lack of confidence on giving sexual consultation may ultimately help patients to improve their quality of life.

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.

Psychological interventions for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

SEARCH METHODS

We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

MAIN RESULTS

This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

AUTHORS' CONCLUSIONS

This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

Attitudes and Performance of Cardiologists Toward Sexual Issues in Cardiovascular Patients

Introduction

The aim of the present study was to evaluate the attitudes and performance of cardiologists regarding sexual issues in patients with cardiovascular diseases.

Methods

A nationwide survey was conducted in a sample of cardiologists, representative of Iranian cardiologists, in 2015.

Main Outcome Measures

Appropriate questionnaires were developed and used to ask participants about their attitudes, performance, and barriers regarding discussing sexual issues with patients with cardiovascular disease.

Results

The study population consisted of 202 cardiologists (138 men and 63 women) with a mean age of 44.25 years (SD = 8.45). Overall, 93.15% of cardiologists agreed with the importance of discussing sexual issues with their patients with cardiovascular diseases. Almost 76.7% of cardiologists agreed they had a responsibility to deal with patients' sexual problems, and 79.9% of them were aware of the association of cardiovascular disease with sexual problems of cardiac patients, but only 33% of them were confident in their knowledge and skills in this regard. Only 10.6% of cardiologists reported they frequently or always assessed sexual problems with their patients, but 51.50% of them stated they were responding to patients' questions about sexual problems. There was a significant association between performance and responsibility.

Conclusion

The results of this study indicate a gap between cardiologist's attitudes and their actual performance and that their professional responsibility to address patients' sexual issues is a significant parameter for better performance.

Sexual counselling for patients with cardiovascular disease: protocol for a pilot study of the CHARMS sexual counselling intervention

INTRODUCTION

Sexual problems are common with cardiovascular disease, and can negatively impact quality of life. To address sexual problems, guidelines have identified the importance of sexual counselling during cardiac rehabilitation, yet this is rarely provided. The Cardiac Health and Relationship Management and Sexuality (CHARMS) intervention aims to improve the provision of sexual counselling in cardiac rehabilitation in Ireland.

METHODS AND ANALYSIS

This is a multicentre pilot study for the CHARMS intervention, a complex, multilevel intervention delivered within hospital-based cardiac rehabilitation programmes. The intervention includes (1) training in sexual counselling for staff, (2) a staff-led patient education and support intervention embedded within the cardiac rehabilitation programme, (3) a patient information booklet and (4) an awareness raising poster. The intervention will be delivered in two randomly selected cardiac rehabilitation centres. In each centre 30 patients will be recruited, and partners will also be invited to participate. Data will be collected from staff and patients/partners at T1 (study entry), T2 (3-month follow-up) and T3 (6-month follow-up). The primary outcome for patients/partners will be scores on the Sexual Self-Perception and Adjustment Questionnaire. Secondary outcomes for patients/partners will include relationship satisfaction; satisfaction with and barriers to sexual counselling in services; sexual activity, functioning and knowledge; physical and psychological well-being. Secondary outcomes for staff will include sexuality-related practice; barriers to sexual counselling; self-ratings of capability, opportunity and motivation; sexual attitudes and beliefs; knowledge of cardiovascular disease and sex. Fidelity of intervention delivery will be assessed using trainer self-reports, researcher-coded audio recordings and exit interviews. Longitudinal feasibility data will be gathered from patients/partners and staff via questionnaires and interviews.

ETHICS AND DISSEMINATION

This study is approved by the Research Ethics Committee (REC) of the National University of Ireland, Galway. Findings will be disseminated to cardiac rehabilitation staff, patients/partners and relevant policymakers via appropriate publications and presentations.

Sexual counseling and cardiovascular disease: practical approaches

Patients with cardiovascular disease and their partners expect health care providers to provide sexual counseling to assist them in maintaining sexual quality of life. Evidence suggests however, that there is a gap in integrating evidence into practice and that relatively few cardiac patients receive sexual counseling. This can result in negative psychological, physical, and quality of life outcomes for couples who may needlessly decide sexual activity is too risky and cease all sexual activity. Two scientific statements now exist that provide ample guidance to health care providers in discussing this important topic. Using a team approach that includes physicians, nurses, physical therapists, rehabilitation staff, and others is important to ensure that sexual counseling occurs throughout recovery. In addition, several trials using interventional approaches for sexual counseling provide insight into successful approaches for sexual counseling in practice. This article provides practical strategies and evidence-based approaches for assessment and sexual counseling for all cardiac patients and their partners, and specific counseling for those with ischemic conditions, heart failure, and implanted devices.

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.

Predictors of change in sexual activity after cardiac diagnosis: Elements to inform sexual counseling

Safely returning to sexual activity after being diagnosed with a cardiac condition is at the core of sexual counseling strategies. To further inform sexual counseling, this study examined changes in sexual activity before and after a cardiac diagnosis. Logistic analysis was used to suggest factors that can contribute to a change in sexual activity among cardiac patients. Reduced frequency in sexual activity after a cardiac diagnosis was influenced by greater sexual concerns and a history of smoking, as well as by education and employment status. These findings suggest that cardiac patients experiencing significant concerns about resuming sexual activity need added support through the mental health system.

When the Topic Turns to Sex: CASE SCENARIOS IN SEXUAL COUNSELING AND CARDIOVASCULAR DISEASE

Patients with cardiovascular disease and their partners frequently have concerns about sexual intimacy, and sexual counseling is needed across health care settings to ensure that patients receive information to safely resume sexual activity. The purpose of this review is to provide practical, evidence-based approaches to enable health care providers to discuss sexual counseling, illustrated by several case scenarios. Evidence shows that patients expect health care providers to initiate sexual activity discussions, although providers may be hesitant and often rely on patients to ask questions. Although some providers cite lack of knowledge or confidence in their ability to provide sexual counseling, others mention time pressures in the clinical setting. Although such barriers exist, sexual counseling can be individualized to the cardiac condition of a patient with a few select questions. The representative examples of patients with angina pectoris, myocardial infarction, coronary artery bypass surgery, heart failure, and implantable cardioverter defibrillator are used to illustrate key points and provide a model for sexual counseling in practice.

Patients’ Experiences of Sexual Activity Following Myocardial Ischemia

The purpose of this article is to describe patients’ experiences of sexual activity after suffering myocardial ischemia. We conducted semi-structured qualitative interviews with people who had suffered myocardial ischemia in the last 6 to 24 months before the interview. We used maximum variation sampling method. After reaching theoretical saturation, a 19-informants sample was formed. Data were analyzed using the Giorgi method. Four themes were identified: “sexual activity becomes different,” “determinants of the return to sexual activity,” “how sexual activity ought to be,” and “sexual information received.” Patients showed a decrease both in frequency and desire for sexual activity influenced by fear of sexual activity and health care professionals’ recommendations. These recommendations were about “avoiding sexuality at the beginning” and conducting “sexual activity without overdoing it.” Health care professionals should educate patients about the right time to resume sexual activity. Nurses can help patients to deal with fears related to sexual activity.

The CopenHeartSF trial--comprehensive sexual rehabilitation programme for male patients with implantable cardioverter defibrillator or ischaemic heart disease and impaired sexual function: protocol of a randomised clinical trial

INTRODUCTION

Sexuality is an important part of people's physical and mental health. Patients with heart disease often suffer from sexual dysfunction. Sexual dysfunction has a negative impact on quality of life and well-being in persons with heart disease, and sexual dysfunction is associated with anxiety and depression. Treatment and care possibilities seem to be lacking. Studies indicate that non-pharmacological interventions such as exercise training and psychoeducation possess the potential of reducing sexual dysfunction in patients with heart disease. The CopenHeartSF trial will investigate the effect of a comprehensive sexual rehabilitation programme versus usual care.

METHODS AND ANALYSIS

CopenHeartSF is an investigator-initiated randomised clinical superiority trial with blinded outcome assessment, with 1:1 central randomisation to sexual rehabilitation plus usual care versus usual care alone. Based on sample size calculations, 154 male patients with impaired sexual function due to implantable cardioverter defibrillator or ischaemic heart disease will be included from two university hospitals in Denmark. All patients receive usual care and patients allocated to the experimental intervention group follow a 12-week sexual rehabilitation programme consisting of an individualised exercise programme and psychoeducative consultation with a specially trained nurse. The primary outcome is sexual function measured by the International Index of Erectile Function. The secondary outcome measure is psychosocial adjustment to illness by the Psychosocial Adjustment to Illness Scale, sexual domain. A number of explorative analyses will also be conducted.

ETHICS AND DISSEMINATION

CopenHeartSF is approved by the regional ethics committee (no H-4-2012-168) and the Danish Data Protection Agency (no 2007-58-0015) and is performed in accordance with good clinical practice and the Declaration of Helsinki in its latest form.

REGISTRATION

Clinicaltrials.gov identifier: NCT01796353.

The Cardiac Health and Assessment of Relationship Management and Sexuality study: a qualitative inquiry of patient, general practitioner, and cardiac rehabilitation staff views on sexual assessment and counseling for cardiac patients

BACKGROUND

Sexual dysfunction is a problem for some patients with cardiovascular disease. This study was the final phase of the Cardiac Health and Assessment of Relationship Management and Sexuality (CHARMS) study of sexual function, assessment, and counseling for people with coronary heart disease in Ireland.

OBJECTIVES

The aim of this study was to explore the perspectives of patients, cardiac rehabilitation staff, and general practitioners on the provision of sexual assessment and counseling within Irish health services and how it can be optimized.

METHODS

Group interviews with cardiac rehabilitation staff (n = 14) and patients (n = 13) and telephone interviews with general practitioners (n = 9) were conducted. The interviews were semistructured, digitally recorded, transcribed verbatim, and analyzed using qualitative, descriptive analysis.

RESULTS

All 3 stakeholder groups reported that the problem of sexual dysfunction among cardiac patients was an important issue that was underaddressed in practice. Patients want the issue to be addressed in an explicit way throughout and after the rehabilitation process by confident and knowledgeable professionals. Cardiac rehabilitators widely acknowledged the role that they could play in the provision of sexual assessment and counseling, but many were constrained by a perceived lack of knowledge and confidence. Most cardiac rehabilitation staff would welcome relevant guidelines and training. General practitioners were unlikely to initiate a discussion about sexual dysfunction; however, most were confident that patients would be comfortable in raising it. General practitioners would welcome more awareness raising but did not identify a need for specific training or resources.

CONCLUSIONS

Perspectives differed both across and within stakeholder groups about current services and the development of future services. A disconnect exists between the service that the professionals perceive they give and that experienced by patients. Sexual assessment and counseling should be addressed more explicitly, and patients should be empowered to seek individual assessment and counseling at a time that is appropriate for them.

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.

A social-cognitive sexual counseling intervention post-MI-development and pilot testing

PURPOSE

Individuals experiencing myocardial infarction (MI) report anxiety, depression, diminished quality of life (QOL), and reduced sexual activity.

DESIGN AND METHODS

We examined return to sexual activity post-MI, and pilot tested a comprehensive sexual counseling intervention based on social-cognitive theory. The intervention in this pretest/posttest preexperimental study used an informational video, newsletters, and telephone counseling, with cardiac patients (N = 10) and partners (N = 3). Measures included QOL; knowledge; sexual anxiety, depression, self-efficacy, and satisfaction.

FINDINGS

At 8 weeks, only 60% had returned to sexual activity, with low QOL and sexual satisfaction for patients and partners.

PRACTICE IMPLICATIONS

Supportive interventions by nurses are needed to assist MI patients and partners return to sexual activity.

Sexual quality of life in patients undergoing coronary artery bypass graft surgery

OBJECTIVES

Despite improvements in many domains of functioning, sexual quality of life often remains impaired following coronary artery bypass graft (CABG) surgery. This study examined associations among sexual quality of life, fear of sexual activity and receiving information from providers about sexual activity in CABG patients.

METHODS

Participants completed a survey assessing sexual activity, mental health and physical health at baseline (3-5-day post-surgery; n=60) and 2-month post-surgery (n=42).

RESULTS

Sexual quality of life showed moderate difficulties at baseline and did not improve by follow-up (p values≥0.09). At follow-up, greater patient fear was associated with lower sexual quality of life in some domains; receiving information was related to lower fear (p values≤0.03) and greater sexual satisfaction and interest (p values≤0.04). Suggestive of mediation, there was a significant indirect effect of information on patient fear and of patient fear on sexual interest (p=0.05).

CONCLUSIONS

Though data were cross-sectional, findings suggest that fears of sexual activity may play a role in lowering CABG patients' motivation for sexual activity and that receiving information from a medical provider may assist in hastening sexual rehabilitation. Prospective and intervention studies are needed to support findings.

Sexual counselling of cardiac patients in Europe: culture matters

BACKGROUND

Sexual problems are common amongst cardiac patients, and concerns may arise when resuming sexual activities after a cardiac event. Sexual counselling is therefore indispensible. Culture is an identified barrier to talking about sex, but research is lacking on whether and how culture influences nurses in providing sexual counselling.

DESIGN

This cross-sectional descriptive study assessed four areas related to sexual counselling provided by cardiovascular nurses. We investigated the impact of culture on these areas by surveying cardiovascular nurses living in Denmark, Norway and two regions of Belgium - Flanders, Dutch-speaking region and Wallonia, French-speaking region.

METHODS

Overall, 819 participants were recruited as they attended cardiovascular nursing congresses in Denmark, Norway and Belgium. Subjects completed the Undertaking Nursing Interventions Throughout Europe (UNITE) sexual counselling questionnaire, measuring practice, responsibility, confidence and perceived comfort of patients. Controlling for demographic, educational and professional covariates, we performed multiple linear regression analysis to determine the impact of culture on sexual counselling.

RESULTS

All four subscale scores were independently associated with culture. Danish nurses counselled patients significantly more often, reported feeling more responsibility and confidence and estimated more comfort in patients than Norwegian, Flemish and Walloon nurses.

CONCLUSIONS

This study showed that culture matters with respect to sexual counselling for cardiac patients. Interventions should be developed improving sexual counselling of cardiac patients. Educational courses and training of healthcare professionals on sexual counselling should be more sensitive to sociocultural differences. Cross-cultural perspectives may bias attitudes of professionals as they deal with concerns of cardiac patients about resuming sexual activity.

Psychological interventions for coronary heart disease

BACKGROUND

Psychological symptoms are strongly associated with coronary heart disease (CHD), and many psychological treatments are offered following cardiac events or procedures.

OBJECTIVES

Update the existing Cochrane review to (1) determine the independent effects of psychological interventions in patients with CHD (principal outcome measures included total or cardiac-related mortality, cardiac morbidity, depression, and anxiety) and (2) explore study-level predictors of the impact of these interventions.

SEARCH STRATEGY

The original review searched Cochrane Controleed Trials Register (CCTR, Issue 4, 2001), MEDLINE, EMBASE, PsycINFO, and CINAHL to December 2001. This was updated by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, PsycINFO and CINAHL from 2001 to January 2009. In addition, we searched reference lists of papers, and expert advice was sought for the original and update review.

SELECTION CRITERIA

Randomised controlled trials of psychological interventions compared to usual care, administered by trained staff. Only studies estimating the independent effect of the psychological component with a minimum follow-up of six months. Adults with specific diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Titles and abstracts of all references screened for eligibility by two reviewers independently; data extracted by the lead author and checked by a second reviewer. Authors contacted where possible to obtain missing information.

MAIN RESULTS

There was no strong evidence that psychological intervention reduced total deaths, risk of revascularisation, or non-fatal infarction. Amongst a smaller group of studies reporting cardiac mortality there was a modest positive effect of psychological intervention (relative risk: 0.80 (95% CI 0.64 to 1.00)). Furthermore, psychological intervention did result in small/moderate improvements in depression, standardised mean difference (SMD): -0.21 (95% CI -0.35, -0.08) and anxiety, SMD: -0.25 (95% CI -0.48 to -0.03). Results for mortality indicated some evidence of small-study bias, though results for other outcomes did not. Meta regression analyses revealed four significant predictors of intervention effects on depression were found: (1) an aim to treat type-A behaviours (ß = -0.32, p = 0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (ß = 0.23, p = 0.03), (3) included client-led discussion and emotional support as core therapeutic components (ß = 0.31, p < 0.01), or (4) included family members in the treatment process (ß = 0.26, p < 0.01) were significantly less effective.

AUTHORS' CONCLUSIONS

Psychological treatments appear effective in treating psychological symptoms of CHD patients. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Sexual Dysfunction before and after Cardiac Rehabilitation

Background. The aim of this study was to assess sexual function before and after cardiac rehabilitation in relation to medical variables. Methods. Analysis of patients participating in a 12-week exercise-based outpatient cardiac rehabilitation program (OCR) between April 1999 and December 2007. Exercise capacity (ExC) and quality of life including sexual function were assessed before and after OCR. Results. Complete data were available in 896 male patients. No sexual activity at all was indicated by 23.1% at baseline and 21.8% after OCR, no problems with sexual activity by 40.8% at baseline and 38.6% after OCR. Patients showed an increase in specific problems (erectile dysfunction and lack of orgasm) from 18% to 23% (P < .0001) during OCR. We found the following independent positive and negative predictors of sexual problems after OCR: hyperlipidemia, age, CABG, baseline ExC and improvement of ExC, subjective physical and mental capacity, and sense of affiliation. Conclusions. Sexual dysfunction is present in over half of the patients undergoing OCR with no overall improvement during OCR. Age, CABG, low exercise capacity are independent predictors of sexual dysfunction after OCR.