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HEART DISEASE CENTER ON HEART BLOCKAGE
Heart Disease Center
Balloon Angioplasty
To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).
Beating-Heart Surgery
Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Complications and Risks of Coronary Artery Bypass Surgery
Coronary artery bypass surgery is recommended only for people who can’t be helped enough by heart medications or angioplasty because it is riskier than these other treatments and requires a longer recovery time. Possible complications of conventional coronary artery bypass surgery include heart attack, bleeding, and stroke. Stroke may occur if blood clots develop and travel to the brain, or if bleeding or periods of low blood pressure deprive the brain of oxygen during the surgery. About 3%–5% of people who undergo coronary artery bypass surgery have a stroke. About 5% suffer a heart attack. The risk for death from conventional coronary artery bypass surgery is about 1%–2%.
As surgical techniques improve, these numbers may go down. It is important to understand that the risk for complications or death from coronary artery bypass surgery is lowest at hospitals that perform the most bypass operations. Once again, for the best results, find an experienced heart surgeon working at a hospital with a high-volume cardiac surgery unit.
Balloon Angioplasty
To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).
Beating-Heart Surgery Close Window
Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Risk of Cognitive Impairment After Coronary Artery Bypass Surgery
A significant number of people experience memory problems or trouble concentrating following a coronary bypass operation, and while this may resolve with time, it is a complication that worries many patients, simply because it is so common. An often-cited study found that about half of the people who underwent coronary artery bypass surgery experienced memory impairment and cognitive decline immediately afterward. Six months later, about one in four people continued to experience cognitive decline, suggesting that the problem is temporary. Yet when the researchers examined the same people five years later, 40% showed signs of cognitive problems.
What is going on? It's not clear. Time on the heart-lung machine during traditional coronary artery bypass surgery is believed to be especially risky for the brain because blood can collect atherosclerotic particles while passing through the heart-lung machine and then deposit them in the brain.
In addition, surgeons have learned that the aorta needs to be handled especially carefully during surgery. Because people undergoing coronary artery bypass surgery have atherosclerosis in their coronary arteries, they also tend to have atherosclerosis in other blood vessels. Twisting or otherwise manipulating the aorta could cause the fragile plaques to crack and flake off into the bloodstream, contributing to strokes or other complications that could damage the memory.
Although it was hoped that off-pump coronary artery bypass surgery would reduce the likelihood of postsurgical cognitive problems, the studies have reported mixed results. Surgeons are now experimenting with and evaluating different operating-room strategies to reduce this complication, such as using special filters in the heart-lung machine to prevent atherosclerotic debris from traveling to the bloodstream, or monitoring the brain during surgery.
To further muddy the waters, a small 2002 study by neurologists who tested people both before and after coronary artery bypass surgery found that they tended to show cognitive decline even before the surgery. Because some research has suggested that some of the biological processes involved in coronary artery disease also contribute to Alzheimer's disease and other types of dementia, the researchers raised the possibility that it is the underlying disease — and not the bypass operation — that may be contributing to cognitive problems.
Researchers continue to look into this issue. But what should you do in the meantime? Talk with your surgeon ahead of time about what strategies are available to minimize the chances of memory and thinking problems. After the operation, mention any problems with attention or concentration you may be having.
Balloon Angioplasty To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).
Beating-Heart Surgery
Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Off-Pump Coronary Artery Bypass Surgery
One less-invasive innovation in coronary artery bypass surgery is a procedure called off-pump bypass or beating-heart surgery because the operating team doesn’t stop your heart and place you on a heart-lung machine. Instead, the surgeon uses special equipment to hold the heart steady, enabling surgeons to operate on it while it continues beating (see Beating-Heart Surgery ).
Several studies have shown that off-pump coronary artery bypass surgery reduces the need for blood transfusion during the operation and results in shorter hospital stays. By avoiding the heart-lung machine, off-pump coronary artery bypass surgery was also expected to lower the rate of some complications, such as strokes and possibly memory impairment and lessened ability to concentrate. So far, though, the results of studies have been mixed. For now, in terms of effectiveness and safety, off-pump and conventional coronary artery bypass surgery seem to be equal.
Heart Surgery
Balloon Angioplasty
To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).
Beating-Heart Surgery Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Minimally Invasive Coronary Artery Bypass Surgery
In minimally invasive direct coronary artery bypass surgery, the surgeon operates without making a large incision and splitting the breastbone, so recovery times are faster and risks are generally lower. This procedure can also be used either with or without the heart-lung machine. However, this procedure can only be used on people with one or two blocked arteries located at the front of the heart.
During the operation, the surgeon makes an incision of 2 1/2–4 inches on the left front side of the chest. To access the heart, the surgeon separates the pectoral muscles and removes a small portion of the front of a rib. Usually a mechanical stabilizer steadies the heart, so that it continues beating while the surgeon performs the bypass operation. However, sometimes it is better to stop the heart, using a video-assisted technique that enables the surgeon to reach more of the heart. If a heart-lung machine is used, the surgeon operates with the help of a videoscope, to see inside the chest even though it has not been opened.
Compared with conventional coronary artery bypass surgery, minimally invasive direct bypass decreases postoperative pain and reduces hospital stays to about three days on average. It is not yet known whether this procedure is as safe and effective (both in the short and long terms) as conventional coronary artery bypass surgery, because no clinical trials comparing the two techniques have yet been reported.
Heart Surgery
Balloon Angioplasty
To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B)
Beating-Heart Surgery
Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Sex After a Heart Attack
If you have cardiovascular disease or have had a heart attack, you may have some concerns about sex. For instance, men with heart disease may experience erectile dysfunction. Erections depend on the arteries that supply blood to the penis, so it makes sense that atherosclerosis is the most common cause of impotence. But high blood pressure, abnormal cholesterol levels, diabetes, and smoking — all leading cardiac risk factors — also increase a man's risk for impotence. To further complicate matters, many heart disease medications may cause erectile dysfunction.
The easy solution — taking an erectile dysfunction medication — may not be feasible. These medications, known as PDE-5 inhibitors, generate nitric oxide, a chemical that enables arteries to widen. The increased blood flow to the penis helps to produce an erection. The problem is that arteries elsewhere in the body widen as well, causing a slight drop in blood pressure. But nitrates also act on nitric oxide, so the combination of nitroglycerin and a PDE-5 inhibitor delivers a one-two punch that can cause a life-threatening drop in blood pressure.
The FDA has urged caution if you have suffered a heart attack, stroke, or serious disturbance of the heart's pumping rhythm in the previous six months, or if you have a history of congestive heart failure or unstable angina, or have low blood pressure or uncontrolled high blood pressure (above 170/110 mm Hg). And all experts agree that you cannot use PDE-5 inhibitors if you have any kind of nitrate in your system already. This means that men who take nitrates on a regular basis should not use PDE-5 inhibitors at all (see Nitroglycerin and Heart Disease). However, if you take nitrates occasionally or keep them on hand in the event you experience angina, you may be able to use PDE-5 inhibitors, but you should talk with your doctor first. Keep in mind that in this circumstance it may be safer to take sildenafil (Viagra) or vardenafil (Levitra) than tadalafil (Cialis), which is a long-acting PDE-5 inhibitor. Men who take Viagra or Levitra cannot take nitrates for 24 hours; with Cialis, you must wait 48 hours.
On the other hand, many people who have had a heart attack fear that having sex could be dangerous, possibly even triggering another heart attack. Research does show that cardiac problems can increase in the hour or two after sexual intercourse, but in reality, the risk is very, very low — even for people who've had heart attacks already. It's about as safe as walking up two flights of stairs. Studies also show that regular exercise markedly reduces the risk for heart attack during or soon after sexual activity.
Some people have angina during sexual activity. If this happens, you should tell your doctor. Doctors often recommend that people in this situation take nitrates before sex to avoid this problem. If you do so, however, it is important that you not use a PDE-5 inhibitor, as noted above.
Balloon Angioplasty
To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).
Beating-Heart Surgery
Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Complications and Risks of Coronary Artery Bypass Surgery
Coronary artery bypass surgery is recommended only for people who can’t be helped enough by heart medications or angioplasty because it is riskier than these other treatments and requires a longer recovery time. Possible complications of conventional coronary artery bypass surgery include heart attack, bleeding, and stroke. Stroke may occur if blood clots develop and travel to the brain, or if bleeding or periods of low blood pressure deprive the brain of oxygen during the surgery. About 3%–5% of people who undergo coronary artery bypass surgery have a stroke. About 5% suffer a heart attack. The risk for death from conventional coronary artery bypass surgery is about 1%–2%.
As surgical techniques improve, these numbers may go down. It is important to understand that the risk for complications or death from coronary artery bypass surgery is lowest at hospitals that perform the most bypass operations. Once again, for the best results, find an experienced heart surgeon working at a hospital with a high-volume cardiac surgery unit.
Balloon Angioplasty
To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).
Beating-Heart Surgery Close Window
Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Risk of Cognitive Impairment After Coronary Artery Bypass Surgery
A significant number of people experience memory problems or trouble concentrating following a coronary bypass operation, and while this may resolve with time, it is a complication that worries many patients, simply because it is so common. An often-cited study found that about half of the people who underwent coronary artery bypass surgery experienced memory impairment and cognitive decline immediately afterward. Six months later, about one in four people continued to experience cognitive decline, suggesting that the problem is temporary. Yet when the researchers examined the same people five years later, 40% showed signs of cognitive problems.
What is going on? It's not clear. Time on the heart-lung machine during traditional coronary artery bypass surgery is believed to be especially risky for the brain because blood can collect atherosclerotic particles while passing through the heart-lung machine and then deposit them in the brain.
In addition, surgeons have learned that the aorta needs to be handled especially carefully during surgery. Because people undergoing coronary artery bypass surgery have atherosclerosis in their coronary arteries, they also tend to have atherosclerosis in other blood vessels. Twisting or otherwise manipulating the aorta could cause the fragile plaques to crack and flake off into the bloodstream, contributing to strokes or other complications that could damage the memory.
Although it was hoped that off-pump coronary artery bypass surgery would reduce the likelihood of postsurgical cognitive problems, the studies have reported mixed results. Surgeons are now experimenting with and evaluating different operating-room strategies to reduce this complication, such as using special filters in the heart-lung machine to prevent atherosclerotic debris from traveling to the bloodstream, or monitoring the brain during surgery.
To further muddy the waters, a small 2002 study by neurologists who tested people both before and after coronary artery bypass surgery found that they tended to show cognitive decline even before the surgery. Because some research has suggested that some of the biological processes involved in coronary artery disease also contribute to Alzheimer's disease and other types of dementia, the researchers raised the possibility that it is the underlying disease — and not the bypass operation — that may be contributing to cognitive problems.
Researchers continue to look into this issue. But what should you do in the meantime? Talk with your surgeon ahead of time about what strategies are available to minimize the chances of memory and thinking problems. After the operation, mention any problems with attention or concentration you may be having.
Balloon Angioplasty To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).
Beating-Heart Surgery
Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Off-Pump Coronary Artery Bypass Surgery
One less-invasive innovation in coronary artery bypass surgery is a procedure called off-pump bypass or beating-heart surgery because the operating team doesn’t stop your heart and place you on a heart-lung machine. Instead, the surgeon uses special equipment to hold the heart steady, enabling surgeons to operate on it while it continues beating (see Beating-Heart Surgery ).
Several studies have shown that off-pump coronary artery bypass surgery reduces the need for blood transfusion during the operation and results in shorter hospital stays. By avoiding the heart-lung machine, off-pump coronary artery bypass surgery was also expected to lower the rate of some complications, such as strokes and possibly memory impairment and lessened ability to concentrate. So far, though, the results of studies have been mixed. For now, in terms of effectiveness and safety, off-pump and conventional coronary artery bypass surgery seem to be equal.
Heart Surgery
Balloon Angioplasty
To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B).
Beating-Heart Surgery Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Minimally Invasive Coronary Artery Bypass Surgery
In minimally invasive direct coronary artery bypass surgery, the surgeon operates without making a large incision and splitting the breastbone, so recovery times are faster and risks are generally lower. This procedure can also be used either with or without the heart-lung machine. However, this procedure can only be used on people with one or two blocked arteries located at the front of the heart.
During the operation, the surgeon makes an incision of 2 1/2–4 inches on the left front side of the chest. To access the heart, the surgeon separates the pectoral muscles and removes a small portion of the front of a rib. Usually a mechanical stabilizer steadies the heart, so that it continues beating while the surgeon performs the bypass operation. However, sometimes it is better to stop the heart, using a video-assisted technique that enables the surgeon to reach more of the heart. If a heart-lung machine is used, the surgeon operates with the help of a videoscope, to see inside the chest even though it has not been opened.
Compared with conventional coronary artery bypass surgery, minimally invasive direct bypass decreases postoperative pain and reduces hospital stays to about three days on average. It is not yet known whether this procedure is as safe and effective (both in the short and long terms) as conventional coronary artery bypass surgery, because no clinical trials comparing the two techniques have yet been reported.
Heart Surgery
Balloon Angioplasty
To open an artery narrowed by plaque, the cardiac surgeon feeds a catheter to the site of the blockage and threads a thin, flexible guide wire through the narrowing (A). The balloon catheter advances along the guide wire until it’s positioned directly inside the narrowed area (B). As the balloon inflates, the plaque stretches and cracks, allowing freer passage of blood through the now-reopened artery (C).
Drug-Coated Stents
One way to prop open a blood vessel is to insert a mesh cage called a stent into the artery. But plaque, in a process called restenosis (A), can gradually clog the stent. To help keep such arteries clear, scientists have developed drug-coated stents (B)
Beating-Heart Surgery
Traditional coronary artery bypass surgery requires the use of a heart-lung machine to circulate the blood while the heart is stopped. In "beating-heart surgery," also known as "off-pump" surgery, devices called stabilizers hold a portion of the heart still, allowing the surgeon to suture bypass vessels in place as the rest of the heart continues to beat. The advantages of this procedure include quicker recovery, reduced trauma to the heart and other organs, and possibly a lessening of memory loss and other neurological consequences.
Sex After a Heart Attack
If you have cardiovascular disease or have had a heart attack, you may have some concerns about sex. For instance, men with heart disease may experience erectile dysfunction. Erections depend on the arteries that supply blood to the penis, so it makes sense that atherosclerosis is the most common cause of impotence. But high blood pressure, abnormal cholesterol levels, diabetes, and smoking — all leading cardiac risk factors — also increase a man's risk for impotence. To further complicate matters, many heart disease medications may cause erectile dysfunction.
The easy solution — taking an erectile dysfunction medication — may not be feasible. These medications, known as PDE-5 inhibitors, generate nitric oxide, a chemical that enables arteries to widen. The increased blood flow to the penis helps to produce an erection. The problem is that arteries elsewhere in the body widen as well, causing a slight drop in blood pressure. But nitrates also act on nitric oxide, so the combination of nitroglycerin and a PDE-5 inhibitor delivers a one-two punch that can cause a life-threatening drop in blood pressure.
The FDA has urged caution if you have suffered a heart attack, stroke, or serious disturbance of the heart's pumping rhythm in the previous six months, or if you have a history of congestive heart failure or unstable angina, or have low blood pressure or uncontrolled high blood pressure (above 170/110 mm Hg). And all experts agree that you cannot use PDE-5 inhibitors if you have any kind of nitrate in your system already. This means that men who take nitrates on a regular basis should not use PDE-5 inhibitors at all (see Nitroglycerin and Heart Disease). However, if you take nitrates occasionally or keep them on hand in the event you experience angina, you may be able to use PDE-5 inhibitors, but you should talk with your doctor first. Keep in mind that in this circumstance it may be safer to take sildenafil (Viagra) or vardenafil (Levitra) than tadalafil (Cialis), which is a long-acting PDE-5 inhibitor. Men who take Viagra or Levitra cannot take nitrates for 24 hours; with Cialis, you must wait 48 hours.
On the other hand, many people who have had a heart attack fear that having sex could be dangerous, possibly even triggering another heart attack. Research does show that cardiac problems can increase in the hour or two after sexual intercourse, but in reality, the risk is very, very low — even for people who've had heart attacks already. It's about as safe as walking up two flights of stairs. Studies also show that regular exercise markedly reduces the risk for heart attack during or soon after sexual activity.
Some people have angina during sexual activity. If this happens, you should tell your doctor. Doctors often recommend that people in this situation take nitrates before sex to avoid this problem. If you do so, however, it is important that you not use a PDE-5 inhibitor, as noted above.
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