Heart failure and sexual activity:
when it is safe and when to avoid it

Article written and reviewed by Dr Luca Moretti

In most people with stable and well-compensated heart failure, sexual activity is possible and should not be avoided as a matter of principle. The exertion required is generally comparable to mild or moderate physical activity, but tolerance varies from person to person.
The most important criterion is not ejection fraction alone: what matters above all is whether the patient can perform daily activities of similar intensity without chest pain, excessive shortness of breath, dizziness, or other important symptoms.

It is useful to discuss this with the physician especially if:

• heart failure has recently decompensated or required hospitalization;
• shortness of breath occurs with very little exertion or even at rest;
• chest pain, dizziness, fainting, or significant palpitations occur;
• unstable ischemic heart disease or an uncontrolled arrhythmia is present;
• you would like to start treatment for erectile dysfunction;
• anxiety or fear of sexual intercourse is significantly limiting the couple's life.

The Heart Failure Association self-care recommendations indicate that sexual activity is compatible with stable heart failure when it does not cause excessive symptoms. Exercise and cardiac rehabilitation can also increase perceived safety and the ability to perform this type of exertion.

How much exertion does sexual intercourse require?

Sexual activity is not maximal exercise. In most situations, it requires an energy expenditure of approximately 3-5 METs, meaning an intensity that is generally mild or moderate. The workload temporarily increases during orgasm, with an increase in heart rate and blood pressure.
These values serve only as a general reference: position, duration, anxiety, ambient temperature, alcohol use, and individual conditions can substantially alter the level of exertion.

A person who tolerates mild-to-moderate daily activities without relevant symptoms is generally likely to tolerate sexual intercourse as well. If marked dyspnea or chest pain already occurs when walking slowly or carrying out minor household activities, it is more prudent to obtain a clinical reassessment first.
The guide on physical activity and heart failure explains how exercise capacity is assessed and progressively increased.

When it is better to postpone sexual activity

During a period of decompensated heart failure, with increasing shortness of breath, edema, orthopnea, or rapid weight gain, the main priority is to restore clinical stability. Sexual activity can be resumed after improvement and, if necessary, after discussing it with the care team.
It is also prudent to postpone it in the presence of unstable angina, significant uncontrolled arrhythmias, symptomatic hypotension, syncope, or other acute cardiovascular conditions.

During sexual activity, you should stop if chest pain, very severe shortness of breath, dizziness, a feeling of impending fainting, persistent palpitations associated with malaise, or sudden weakness occurs. If symptoms are severe or do not resolve quickly with rest, urgent assessment is required.
Anyone who has recently experienced deterioration can also consult the guide on warning signs of heart failure.

Why sexual desire and function may change

Sexual dysfunction is common in heart failure in both men and women. Contributing factors can include fatigue, dyspnea, reduced physical capacity, diabetes, vascular disease, depression, anxiety, hormonal changes, and fear that sexual activity may harm the heart.
In men, the most evident problem is often erectile dysfunction; in women, reduced desire, difficulty with arousal, vaginal dryness, or pain may occur.

Some medications can also contribute to sexual problems, but it is often difficult to separate the effect of treatment from that of the disease and comorbidities. Stopping a beta-blocker or other heart failure medications on your own in an attempt to improve sexual function can increase cardiovascular risk.
It is preferable to describe the problem openly to the physician: in many cases, reversible factors can be corrected, alternative therapies can be considered, or the dysfunction can be treated directly.

Sildenafil and other medications for erectile dysfunction

Phosphodiesterase-5 inhibitors, such as sildenafil, tadalafil, and vardenafil, are used for erectile dysfunction and are generally compatible with stable heart disease when there are no specific contraindications. The most important safety rule is that they must not be combined with nitrates because the combination can cause a marked fall in blood pressure.
Nitrate therapy includes, for example, nitroglycerin and isosorbide used for angina. It is therefore essential to tell the physician about all medications being taken before using erectile dysfunction products, even if purchased online or without specialist assessment.

Cardiovascular recommendations indicate that nitrates should not be taken for at least 24 hours after sildenafil or vardenafil and for at least 48 hours after tadalafil. If chest pain occurs after taking an erectile dysfunction medication, this must be reported immediately to healthcare professionals because it changes nitrate management.
Erectile dysfunction medications are not a treatment for heart failure and should not be started with the aim of improving cardiac function.

How to resume sexual activity more safely and with less anxiety

After a period of illness or a hospitalization, it is common to be afraid of resuming sexual activity. Gradually returning to normal physical activities, following a rehabilitation program when indicated, and choosing a time when you feel rested can reduce anxiety.
It may be useful to avoid sexual intercourse immediately after a very large meal, after high alcohol intake, or in very hot environmental conditions, situations that can increase fatigue or alter blood pressure.

Communication with the partner is as important as the physical component. Fear, depression, and changes in body image can reduce desire and satisfaction even when the heart is clinically stable. If the problem persists, cardiology, andrology, gynecology, or sexology assessment can help distinguish the different causes and identify an appropriate solution.

Frequently asked questions about heart failure and sexual activity

Can you have sex if you have heart failure?
In most people with stable, well-compensated heart failure, sexual activity is generally compatible with the cardiac condition. Safety depends mainly on clinical stability and the ability to tolerate mild or moderate exertion without important symptoms.

When is it better to avoid sexual activity?
It is prudent to postpone sexual activity during a period of decompensated heart failure or when there is unstable chest pain, severe shortness of breath at rest or with minimal exertion, dizziness or syncope, significant arrhythmias, or other uncontrolled cardiovascular conditions.

Can sex cause heart failure to worsen?
Sexual activity generally involves mild or moderate physical exertion. In stable patients the risk is low; however, if the same symptoms occur even during modest everyday activities, it is appropriate to discuss this with the cardiologist before resuming sexual activity.

Can sildenafil be used with heart failure?
PDE5 inhibitors may be usable in people with stable heart disease, but they must not be combined with nitrates because the combination can cause severe hypotension. Compatibility with the individual medication regimen must be checked by a physician.

Should heart failure medications be stopped if they cause sexual problems?
No. Medications that reduce hospitalizations and mortality should not be stopped on your own. Sexual dysfunction may be related to the disease, comorbidities, anxiety, or medications; the problem should be discussed to find a solution without compromising cardiac therapy.