Heart health and low effort: sex with heart disease or low energy

Is sex safe if you have heart disease?

In most cases, yes. The American Heart Association scientific statement (Levine and colleagues, Circulation, 2012) estimates that sexual activity takes 3 to 5 METs: light to moderate physical activity, comparable to climbing two flights of stairs. Heart rate and blood pressure rise most only at orgasm, and that peak lasts about 10 to 15 seconds.

The risk is real but small: the same statement estimates that sexual activity triggers around 1% of heart attacks. Fitness matters a great deal: in the studies it reviews, the rise in risk during sex was much greater in sedentary people than in those who exercised regularly.

The British Heart Foundation suggests a simple check: if you can walk a mile on the flat in about 20 minutes or climb two flights of stairs comfortably, sex is usually fine. If you are unsure, ask your cardiology team: it is a common question.

When to start again: heart attack, heart failure and high blood pressure

• After an uncomplicated heart attack: the American Heart Association considers it reasonable to resume sex from one week if light to moderate activity causes no symptoms. The British Heart Foundation says, in general, between 2 and 8 weeks depending on your recovery. Your team can tell you which timeframe applies to you.
• After heart surgery: it usually takes longer. A small, soft cushion over the wound, between you and your partner, helps avoid pressure.
• Heart failure: sex is reasonable if it is compensated or mild (class I or II). If it is decompensated or advanced (class III or IV), it is best to wait until it has been stabilised.
• High blood pressure: the statement sets no limits for hypertension itself. If a blood pressure medicine affects your erections or desire, do not stop it on your own: mention it, because it can often be changed or adjusted.

Cardiac rehabilitation and regular exercise help reduce the risk during sex, according to the same statement. Getting fitter also gives you more leeway in bed.

Medicines: nitrates and erection medicines

This is the most important warning in this guide. Erection medicines in the PDE5 inhibitor group (sildenafil, tadalafil, vardenafil) must never be used with nitrates (glyceryl trinitrate spray or tablets for angina, among others). Both lower blood pressure and, combined, can drop it to a dangerous level.

• The American Heart Association advises against giving nitrates within 24 hours of taking sildenafil or vardenafil, or within 48 hours of tadalafil.
• If you have chest pain and have taken one of these medicines, tell the emergency team: it changes the treatment they can give you.
• If you have been prescribed glyceryl trinitrate, keep it within reach on the bedside table and ease into sexual activity slowly.
• Do not buy erection medicines online without a prescription: they may contain unknown doses or other substances.

With fatigue, COPD or while recovering

Low energy does not always come from the heart. COPD, convalescence, long treatment or built-up tiredness also sap desire and stamina. Asthma + Lung UK, the British lung health charity, offers several tips that work for any kind of fatigue:

• Choose the time when you feel best. If breathing is harder at night, try the morning.
• Let your partner know you may need breaks, and take them without guilt.
• Avoid lying completely flat on your back, weight on your chest and holding yourself up on your arms for long periods.
• Sex is safe if you use oxygen at home. Ask your team whether to turn up the flow during activity, and avoid oil-based products: use a water- or silicone-based lubricant.

When you are tired, desire often does not come first but once touch begins. Understanding the difference between spontaneous and responsive desire takes the pressure off: you do not need to feel like it to start with a caress.

Slow sex and other ways to use less energy

1. Go slowly. Slow sex puts the focus on a gentle pace, calm breathing and whole-body contact. Keep breathing steadily and do not hold your breath while making an effort.
2. Avoid heavy meals and alcohol beforehand. The British Heart Foundation points out that indigestion can be mistaken for chest pain and that alcohol can make you lightheaded.
3. Keep the room at a comfortable temperature: neither too hot nor too cold.
4. Share the work. The person with less energy can stay in a supported position and let their partner take more of the movement.
5. Use cushions and supports so arms and legs do not bear weight. The reduced mobility and arthritis guide has ideas on where to place them.
6. Count non-penetrative sex. Kissing, massage and caressing take less effort and are sex in every sense.

If fear or a gap in desire starts to weigh on the relationship, it helps to name what is happening: see how to talk about desire discrepancy in couples.

Signs to stop and when to call emergency services

Stop and rest if, during or after sex, you notice:

• pain, pressure or tightness in the chest;
• breathlessness much worse than usual for that effort;
• palpitations or an irregular heartbeat;
• dizziness, a cold sweat or feeling faint.

If you have angina and a glyceryl trinitrate plan, follow it, unless you have taken a PDE5 inhibitor within the timeframes above.

Call emergency services (999 in the UK, 112 across Europe, 911 in North America) if you have:

• chest pain that feels crushing or tight, spreads to the arms, neck or jaw, or does not settle when you stop;
• severe difficulty breathing or speaking;
• pale, blue or grey lips or skin;
• loss of consciousness.

Do not drive yourself to A&E: the call handler will tell you what to do while help is on its way. Book a routine appointment if symptoms keep coming back, if tiredness after sex lasts into the next day, or if erection problems or low desire appear.

Low-effort positions and practices

Chosen by goal: no weight-bearing, plenty of support and room to go slowly. Try them with the adjustments above and stop whenever you need to.

Lying on your sides, no weight-bearing

The SpoonBajo

Both partners lie on their sides, supported by the bed: nobody holds up their weight and the chest stays free to breathe. Allows short, slow movements.

The Half Moon EncounterBajo

On your sides, face to face and holding each other: the mattress supports you and it is easy to pause, talk or check how your partner is doing.

Deep LongingBajo

Face to face on your sides in a close embrace: small movements, low effort and a lot of closeness.

Side-by-Side Face to FaceBajo

Lying on your sides facing each other, with no arms or knees bearing weight. A cushion between the legs adds comfort.

Seated, with back support

Tantric Sex (Slow Sex)Bajo

A seated face-to-face embrace with a very slow pace and synchronised breathing: the heart of slow sex, with pauses that keep you in contact.

The Lotus FlowerBajo

Sitting face to face keeps the upper body upright and the chest free of pressure, which helps breathing more than lying flat on your back.

On a Chair (Straddling)Bajo

The partner with less energy sits on a sturdy chair with a backrest and feet on the floor; the partner on top sets a short rocking motion.

The Cobra (Embracing Hug)Bajo

Face to face in a wrap-around embrace, rocking gently instead of thrusting: the effort is shared and nobody holds themselves up on their arms.

The partner with less energy underneath or reclining

The MissionaryBajo

The partner underneath bears no weight. With pillows raising the head and chest, and the other partner not leaning on their chest, it is more comfortable.

The Queen's ChairBajo

The receiving partner reclines at the edge of the bed and barely moves; the other partner, kneeling or sitting on the floor, sets the pace.

Pleasure without penetration

Foreplay (Preliminaries)Bajo

Unhurried kissing and touching: little energy, easy to stop whenever needed, and sex in its own right, not just a warm-up.

Mutual Manual StimulationBajo

Touching each other with your hands at the same time, lying down or sitting with support: low effort, lots of control and easy to pause.

Erotic MassageBajo

A slow massage relaxes, encourages calm breathing and lets desire build without pressure to reach any goal.

The ScissorsBajo

Genital rubbing without penetration, with weight spread across the bed; the movement is short and each partner controls the pressure.

The ScorpionBajo

Mutual oral sex lying on your sides: nobody holds up their weight and the chest is not compressed.

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