Author + information
- Published online November 12, 2017.
- Aapo L. Aro, MD, PhD,
- Carmen Rusinaru, MD, PhD,
- Audrey Uy-Evanado, MD,
- Harpriya Chugh, BS,
- Kyndaron Reinier, MPH, PhD,
- Eric C. Stecker, MD, MPH,
- Jonathan Jui, MD, MPH and
- Sumeet S. Chugh, MD∗ ()
- ↵∗Cedars-Sinai Medical Center, Heart Institute, Advanced Health Sciences Pavilion, Suite A3100, 127 South San Vicente Boulevard, Los Angeles, California 90048
Sexual activity is an important aspect of quality of life, and is associated with both health and mortality benefit (1). Nonetheless, it is not without risk. In a study from Germany, 0.2% of autopsied natural deaths were linked to sexual activity (2). It is also recognized that sexual activity may trigger nonfatal acute cardiac events such as myocardial infarction. Sudden cardiac arrest (SCA), which manifests as an unexpected collapse and loss of the pulse, is a mostly lethal condition that results in over 300,000 deaths annually in the United States. Physical activity, especially when nonhabituated, has been associated with increased risk of SCA (3). To our knowledge, there is no available information on sexual activity as a potential trigger for SCA in the general population.
The community-based Oregon SUDS (Sudden Unexpected Death Study) study, ongoing since 2002, uses multiple-source ascertainment to prospectively identify cases of SCA that occur in the Portland, Oregon, metropolitan area (catchment population approximately 1 million) (4). All SCA cases are adjudicated based on emergency medical services reports containing detailed circumstances of the cardiac arrest event, lifetime medical records, and autopsy data. Emergency medical services personnel record the individual’s location, activity, and circumstances of SCA. We included all subjects over 18 years of age, ascertained between 2002 and 2015. All SCA cases that occurred during or within 1 h of sexual intercourse were considered as related to sexual activity (sex-SCA).
For comparisons between sex-SCA versus all other SCA cases, independent sample Student's t-test, Pearson’s chi-square test and Fisher exact test were used. For calculation of SCA incidence rates, analysis was limited to the first 10 years from Multnomah County, the largest subset of the Portland metropolitan area (average population >18 years of age = 544,370).
A total of 4,557 SCAs were identified (mean 65.2 ± 16.3 years of age; 68.0% men). Of these, 4,525 (99.0%) had detailed information available to determine whether sexual activity preceded SCA. Overall, 34 (0.7%) of SCAs were linked to sexual activity, yielding an annual incidence of 0.28 per 100,000 adults. SCA occurred during sexual activity in 18 (55.0%) of these cases, and within minutes after cessation of sexual activity in 15 (45.0%) cases. For one case, exact timing could not be determined. Of the sex-SCA cases, 32 (94.0%) were men. Among men, sex-SCA was responsible for 1.0% of overall SCA burden, compared with 0.1% among women.
Individuals with sex-SCA were on average 5 years younger (range 34 to 83 years of age) and more likely to be African American than were the rest of the SCA cases (Table 1). Cardiac comorbidities were relatively common in both groups. Among those with sex-SCA, 29% of patients had a history of coronary artery disease, 26% had symptomatic heart failure, and the majority were taking cardiovascular medications.
Sex-SCA was more likely to present with ventricular fibrillation or tachycardia than other SCA (76% vs. 45%; p < 0.001), and this finding remained consistent in a sensitivity analysis of subjects with witnessed cardiac arrest. Only one-third of the sex-SCA cases received bystander cardiopulmonary resuscitation (CPR). There was a nominal difference in survival between the 2 groups (Table 1), likely explained by the differences in rates of shockable rhythms.
We observed a relatively low overall burden of SCA related to sexual activity in the community, with the vast majority of cases confined to men. Although sexual activity involves exertion, the mechanisms triggering SCA may be unique, and in some situations may also involve medications, stimulants, and alcohol use. The absolute risk of sex-SCA appears to be extremely low, even among subjects with clinical heart disease that have a prevalence of 7% to 10% in the community. However, we lacked information on the overall frequency of sexual activity and could not assess relative risk compared to rest and physical activity. These findings have implications for cardiac patients as well as health care professionals, advising them on the safety of engaging in sexual activity. Moreover, even though SCA during sexual activity was witnessed by a partner, bystander CPR was performed in only one-third of the cases. This likely explains the relatively low survival rates despite mostly shockable initial cardiac arrest rhythms. Therefore, these findings also highlight the importance of continued efforts to educate the public on the importance of bystander CPR for SCA, irrespective of the circumstance.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation
- Davey Smith G.,
- Frankel S.,
- Yarnell J.
- Chugh S.S.,
- Jui J.,
- Gunson K.,
- et al.