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Intimate relationships and sexual function in partnered patients in the year before and one year after a myocardial infarction: A longitudinal study

Intimate relationships and sexual function in partnered patients in the year before and one year... Abstract Background Intimate relationships and sexuality are essential to an individual’s health and longevity after a myocardial infarction (MI). Aims To explore and compare partnered first-time MI patients’ ratings of intimate relationship satisfaction and sexual function before the MI as compared to one year after the event. Methods Longitudinal study with 92 men and 36 women, aged 62.4±9.3 years. Self-reported data was collected one year before, and one year after, the MI. Results The majority were sexually active before (86%) as well as after (80%) their MI (ns). High satisfaction was reported with intimate relationships, which were stable over time (Relationship assessment scale score 4.56±0.50 and 4.53±0.52, respectively, ns). No significant differences in intimate relationships between genders were found. Women reported lower ratings in their sexual function than men before the MI (Watts sexual function score 45.92±6.55 and 48.59±4.96, respectively, P<0.05). The year after the event, women described an unchanged sexual function (45.08±7.25), while men (47.10±5.16) had decreased theirs (P<0.05). Both female and male patients enjoyed sexual activity less frequently the subsequent year. Men regarded having sex as being less important in their lives, were less satisfied with the frequency of sexual activity, and felt that they more often ejaculated prematurely the year after the MI. Conclusions Partnered first-time MI patients continue to be sexually active the year after the event, and are highly satisfied with their intimate relationship. While the MI event seems to have a more negative impact on men’s sexual functioning than women’s, the women still rate their sexual function lower in comparison. Gender, myocardial infarction, relationship assessment scale, sexual counselling, Watts sexual function questionnaire Introduction After a myocardial infarction (MI), patients often have to deal with consequences of the disease, or its treatment, on their everyday life and functioning, which may lead to impaired quality of life.1 Therefore, cardiac rehabilitation (CR) should be offered to all patients after a cardiac event to help them cope with their new life situation.2 This multifaceted programme will increase survival, decrease subsequent cardiac events, and improve quality of life.3,4 Intimate relationships including dyadic quality, spousal satisfaction and intimacy are essential to people’s health and longevity after a cardiac event.5,6 Sexual functioning in married life has consequently become an important component when measuring quality of life in clinical research in patients with heart disease.7–9 Sexually inactive older adults – as well as those with other chronic or life-threatening illnesses – also value sexuality as an important part of life and health.10–13 Identification of sexual problems has therefore been recommended as a component of psychosocial management in CR programmes.14,15 However, few of the healthcare professionals working with cardiovascular patients are addressing questions related to the intimate relationship on a regular basis.16–18 Potential explanations for the lack of attention towards sexual matters are mainly due to a lack of sexual knowledge,16–18 time constraints,18 a belief that that their patients could be upset, embarrassed or anxious,17 or lack of initiative on the part of the patient;18 with the latter also being reported from the patient’s perspective.19 Lack of sexual counselling during the CR has been found to be associated with loss of sexual activity the year after the MI.19 Approximately 45% of couples at a given time suffer sexual problems.20 When our research group investigated partners’ intimate relationship both before and after the patients’ MI, we found that they were highly satisfied with their relationship.21 However, more evidence is needed to obtain a better understanding of patients’ concerns and to facilitate marital communication and satisfaction related to an acute MI event. Therefore, the aim of this longitudinal study was to: explore and compare partnered first-time MI patients’ ratings of intimate relationship satisfaction and sexual function before the MI as compared to one year after the event; explore if any gender differences exist in intimate relationships and sexual functions; and describe if any sexual counselling had been received in the CR programme and the perceived quality of the same. Methods Design, setting and participants This multicentre study is a substudy of sexual and marital life in a myocardial infarction (SAMMI) context project (www.sammi.dinstudio.se). A descriptive and exploratory study design was used with data from one year before the MI event (retrospectively collected approximately 3 weeks after the MI) and the subsequent year after the event. This national survey study enrolled participants from 13 hospitals in Sweden: four university hospitals and nine county hospitals. The hospitals were selected by a stratified sampling method based on a divergent geographical location and type of hospital. Patients with a first time MI who had been hospitalized at one of the participating hospitals were consecutively recruited over a period of 20 months in 2007–2009, which ended with a one-year follow-up from 2008 to 2010. The inclusion criteria were as follows: the patient met criteria for a first MI; was admitted, and planned to attend the follow-up at a cardiac outpatient programme at the hospital; lived in a relationship for at least one year. The exclusion criteria were: difficulty reading and speaking Swedish; mental disorder; expected survival less than one year; or participating in another study. Ethics The investigation conforms with the principles outlined in the Declaration of Helsinki.22 The Regional Research Ethics Committee at Linköping University, Linköping, Sweden, approved the study (D-nr: 104-07). All patients gave written consent after having received written and oral information about the study. They were also informed that they could withdraw from the study at any time without any explanation or consequence. Furthermore, the patients were assured that data would be treated strictly confidentially. Measures and instruments Demographic and clinical variables Demographic data, data on comorbidities and health complaints, data on sexual health (e.g. frequency of sexual activity, symptoms during intercourse), as well as data on sexual information obtained from the healthcare professionals, were all collected by self-report. Relationship assessment scale The Swedish version of the Relationship assessment scale (RAS) was used to evaluate the intimate relationship.23 The original RAS, developed by Hendrick, contains seven questions on a scale from 1 to 5 (5 being most satisfied) focusing on relationship satisfaction in healthy couples. Either the average or the total scores (7–35) can be used for comparisons.24 RAS was translated into Swedish following a back-and-forward method25 and tested for psychometric properties in a population of persons with cardiac disease.23 One item with low communality was excluded, giving a six-item RAS with a two-factor solution: ‘Relationship built on expectations and satisfaction of needs’ (factor 1) and ‘Relationship built on love and devotion’ (factor 2).23 The possible total scores thus range from 6 to 30 in the Swedish version. In the present study, the Cronbach’s alpha coefficient, including responses from all patients at time 1 (T1), was 0.75 for RAS factor 1 and 0.64 for RAS factor 2. At time 2 (T2), the corresponding coefficients were 0.76 and 0.79 for RAS factor 1 and RAS factor 2, respectively. Watts sexual function questionnaire The Swedish version of the Watts sexual function questionnaire (WSFQ) was used to evaluate sexual function. The instrument is divided into ‘sexual appetite’ and ‘sexual expectations’ with gender-neutral questions, and ‘sexual sensitiveness’ and ‘sexual ability’ with gender-specific questions.26 The male questionnaire contains items that focus on male sexual problems related to erectile and orgasmic capability (premature ejaculation and ejaculatory incompetence); whereas the female form addresses the common sexual problems of women with specific emphasis on vaginal lubrication and orgasmic capability.26 The original WSFQ contains 17 questions in which the respondents rate their answers on a 5-point Likert scale ranging from 1=never to 5=always. Items 10, 13 and 17 are reverse scored for men and items 10 and 17 for women, that is, 5=never and 1=always.27 The Swedish version has been shortened to 13 questions with the total score thus ranging from 13 to 65 with higher scores indicating a more positive sexual functioning. The Swedish version of the WSFQ has good validity and stability and acceptable internal homogeneity with Cronbach’s alpha coefficients ranging from 0.48 to 0.86 and test–retest values for all but one question exceeding 0.70.26 In the present study, the Cronbach’s alpha coefficient for the total WSFQ, including responses from all patients at T1, was 0.82 for women and 0.64 for men. At T2, the corresponding coefficients were 0.85 and 0.69 for women and men, respectively. Procedures Participants completed the questionnaires approximately 3 weeks after the MI (T1). At T1, patients were asked to report on their intimate relationship and sexual function during the year prior to the event. Identical questionnaires were again sent one year after the MI (T2), asking about the intimate relationship, sexual function and perceived quality of sexual counselling – if any – during the last year. One reminder was sent 3 weeks after each questionnaire was posted. In all, 218 patients (63 women and 155 men) met the inclusion criteria. Of those, 180 (52 women and 128 men) participated at T1, leading to a response rate of 82.6%. At T2, 52 patients did not answer the questionnaires, giving 128 responding participants (response rate based on the initial 218 patients who met the inclusion criteria: 58.7%, 36 women and 92 men). No statistically significant differences were found between patients who participated at both times as compared to those who only took part on the first occasion with regard to background characteristics, self-rated sexual health, or total RAS and WSFQ ratings at T1. Statistics Data are presented as descriptive statistics with means and standard deviations and percentages. Differences in the means (i.e. age) were analysed with the two-tailed Student’s t test. Differences in proportions were tested with the χ2 test. To compare differences in general relationship satisfaction and sexual function between two independent groups (i.e. gender) we used the Mann–Whitney U test for non-normally distributed samples. Likewise, differences in total scores in matched pairs were tested with the Wilcoxon rank sum test for non-normally distributed samples when comparing differences between TI and T2. A P value of less than 0.05 was considered to indicate a statistically significant difference. Data were analysed using SPSS 20.0 for Windows (SPSS, Inc., Chicago, IL, USA). Results A total of 128 patients, 92 men (72%), and with a mean age of 62.4±9.3 years, answered the questions on both occasions. These patients reported that they had lived with their current partner between one and 63 years with an average of 31 years. Twenty-eight per cent reported problems with tiredness, 15% had sleep disturbances and 11% suffered from anxiety; all were more common in women. The background characteristics and comparisons between genders are further presented in Table 1. Table 1. Background characteristics, N=128 Characteristics . . Valueb . . . Demographics Totala Womena Mena P value Gender (male) 92 (72) Age, years 62.4±9.3 61.3±9.5 62.8±9.2 ns Compulsory school (≤9 years) 57 (44.9) 16 (45.7) 41 (44.6) ns Years as a couple 31.3±16.1 32.9±15.4 30.7±16.4 ns Children in the household (yes) 17 (13.3) 5 (13.9) 12 (13.0) ns Sexual health Sexually active the last year (yes) 108 (85.7) 31 (88.6) 77 (84.6) ns Symptoms during intercourse (yes) 12 (9.8) 3 (9.1) 9 (10.0) Health complaints Chest pain 8 (6.5) 3 (9.4) 5 (5.4) ns Dyspnea 16 (12.8) 6 (17.6) 10 (11.0) ns Tiredness 35 (28.5) 17 (53.1) 18 (19.8) <0.001 Sleep disturbances 19 (15.1) 11 (31.4) 8 (8.8) <0.01 Dizziness 8 (6.5) 4 (12.5) 4 (4.4) ns Anxiety 13 (10.5) 7 (21.2) 6 (6.6) <0.05 Worries 12 (9.7) 5 (15.2) 7 (7.7) ns Mobility problems 13 (10.8) 3 (9.4) 10 (11.4) ns Comorbiditiesc Angina pectoris 21 (16.4) 2 (5.6) 19 (20.7) ns Hypertension 45 (35.2) 13 (36.1) 32 (34.8) ns Stroke 7 (5.5) 3 (8.3) 4 (4.3) ns Diabetes 20 (16.4) 7 (20.0) 13 (14.9) ns Asthma/COPD 17 (14.5) 7 (21.9) 10 (11.8) ns Characteristics . . Valueb . . . Demographics Totala Womena Mena P value Gender (male) 92 (72) Age, years 62.4±9.3 61.3±9.5 62.8±9.2 ns Compulsory school (≤9 years) 57 (44.9) 16 (45.7) 41 (44.6) ns Years as a couple 31.3±16.1 32.9±15.4 30.7±16.4 ns Children in the household (yes) 17 (13.3) 5 (13.9) 12 (13.0) ns Sexual health Sexually active the last year (yes) 108 (85.7) 31 (88.6) 77 (84.6) ns Symptoms during intercourse (yes) 12 (9.8) 3 (9.1) 9 (10.0) Health complaints Chest pain 8 (6.5) 3 (9.4) 5 (5.4) ns Dyspnea 16 (12.8) 6 (17.6) 10 (11.0) ns Tiredness 35 (28.5) 17 (53.1) 18 (19.8) <0.001 Sleep disturbances 19 (15.1) 11 (31.4) 8 (8.8) <0.01 Dizziness 8 (6.5) 4 (12.5) 4 (4.4) ns Anxiety 13 (10.5) 7 (21.2) 6 (6.6) <0.05 Worries 12 (9.7) 5 (15.2) 7 (7.7) ns Mobility problems 13 (10.8) 3 (9.4) 10 (11.4) ns Comorbiditiesc Angina pectoris 21 (16.4) 2 (5.6) 19 (20.7) ns Hypertension 45 (35.2) 13 (36.1) 32 (34.8) ns Stroke 7 (5.5) 3 (8.3) 4 (4.3) ns Diabetes 20 (16.4) 7 (20.0) 13 (14.9) ns Asthma/COPD 17 (14.5) 7 (21.9) 10 (11.8) ns a Some missing responses, which explain the differences in the percentages. b Data are presented as mean±SD or n (%). c Self-reported by subjects. COPD: chronic obstructive pulmonary disease. Open in new tab Table 1. Background characteristics, N=128 Characteristics . . Valueb . . . Demographics Totala Womena Mena P value Gender (male) 92 (72) Age, years 62.4±9.3 61.3±9.5 62.8±9.2 ns Compulsory school (≤9 years) 57 (44.9) 16 (45.7) 41 (44.6) ns Years as a couple 31.3±16.1 32.9±15.4 30.7±16.4 ns Children in the household (yes) 17 (13.3) 5 (13.9) 12 (13.0) ns Sexual health Sexually active the last year (yes) 108 (85.7) 31 (88.6) 77 (84.6) ns Symptoms during intercourse (yes) 12 (9.8) 3 (9.1) 9 (10.0) Health complaints Chest pain 8 (6.5) 3 (9.4) 5 (5.4) ns Dyspnea 16 (12.8) 6 (17.6) 10 (11.0) ns Tiredness 35 (28.5) 17 (53.1) 18 (19.8) <0.001 Sleep disturbances 19 (15.1) 11 (31.4) 8 (8.8) <0.01 Dizziness 8 (6.5) 4 (12.5) 4 (4.4) ns Anxiety 13 (10.5) 7 (21.2) 6 (6.6) <0.05 Worries 12 (9.7) 5 (15.2) 7 (7.7) ns Mobility problems 13 (10.8) 3 (9.4) 10 (11.4) ns Comorbiditiesc Angina pectoris 21 (16.4) 2 (5.6) 19 (20.7) ns Hypertension 45 (35.2) 13 (36.1) 32 (34.8) ns Stroke 7 (5.5) 3 (8.3) 4 (4.3) ns Diabetes 20 (16.4) 7 (20.0) 13 (14.9) ns Asthma/COPD 17 (14.5) 7 (21.9) 10 (11.8) ns Characteristics . . Valueb . . . Demographics Totala Womena Mena P value Gender (male) 92 (72) Age, years 62.4±9.3 61.3±9.5 62.8±9.2 ns Compulsory school (≤9 years) 57 (44.9) 16 (45.7) 41 (44.6) ns Years as a couple 31.3±16.1 32.9±15.4 30.7±16.4 ns Children in the household (yes) 17 (13.3) 5 (13.9) 12 (13.0) ns Sexual health Sexually active the last year (yes) 108 (85.7) 31 (88.6) 77 (84.6) ns Symptoms during intercourse (yes) 12 (9.8) 3 (9.1) 9 (10.0) Health complaints Chest pain 8 (6.5) 3 (9.4) 5 (5.4) ns Dyspnea 16 (12.8) 6 (17.6) 10 (11.0) ns Tiredness 35 (28.5) 17 (53.1) 18 (19.8) <0.001 Sleep disturbances 19 (15.1) 11 (31.4) 8 (8.8) <0.01 Dizziness 8 (6.5) 4 (12.5) 4 (4.4) ns Anxiety 13 (10.5) 7 (21.2) 6 (6.6) <0.05 Worries 12 (9.7) 5 (15.2) 7 (7.7) ns Mobility problems 13 (10.8) 3 (9.4) 10 (11.4) ns Comorbiditiesc Angina pectoris 21 (16.4) 2 (5.6) 19 (20.7) ns Hypertension 45 (35.2) 13 (36.1) 32 (34.8) ns Stroke 7 (5.5) 3 (8.3) 4 (4.3) ns Diabetes 20 (16.4) 7 (20.0) 13 (14.9) ns Asthma/COPD 17 (14.5) 7 (21.9) 10 (11.8) ns a Some missing responses, which explain the differences in the percentages. b Data are presented as mean±SD or n (%). c Self-reported by subjects. COPD: chronic obstructive pulmonary disease. Open in new tab The majority (86%) described that they had been sexually active the year before the MI event, while 80% reported that they had been sexually active the year after the event (ns). Most of the women (62%) reported having intercourse at least once a week at T1, and the corresponding frequency for the men was 67%. Both half of the women (50%) as well as the men (58%) reported having had intercourse at least once a week also the year after the MI event, which was a statistically significant reduction for the men (P<0.001) but not for the women. However, every tenth (10%) patient described troublesome symptoms during intercourse, such as erectile problems, vaginal dryness, shortness of breath, palpitations and chest pain, with no statistically significant differences between T1 and T2. About one third (36%) had received sexual counselling by healthcare professionals the year after the MI event (43% of the women and 33% of the men, ns). The majority of those patients (73%) rated the information as ‘good’ or ‘very good’. Sexual counselling was not associated with being sexually active or not during the subsequent year (36% vs. 44%, ns). General relationship satisfaction The patients scored a high general relationship satisfaction on both dimensions in the RAS; ‘Relationship built on expectations and satisfactions of needs’ (4.45±0.58 and 4.41±0.60, T1 and T2, respectively, ns), and ‘Relationship built on love and devotion’ (4.76±0.56 and 4.77±0.57, T1 and T2, respectively, ns), before (T1) as well as one year after the MI event (T2). All single item scores were also stable over time. Both at T1 and T2, the patients were most satisfied with how much they loved their partner (4.82±0.54 and 4.83±0.53, T1 and T2, respectively), while at T1 they had the lowest satisfaction with how well the partner meet their needs (4.25±0.79), and at T2 to what extent their relationship met their original expectations (4.31±0.87). No statistically significant differences between genders were found, see Table 2. Table 2. Intimate relationships measured with the Swedish version of the relationship assessment scale: patients, N=128 (women n=36, men n=92) Item content . Proportions of high satisfaction at T1, n (%)a . Mean score (SD) . P valueb . Proportions of high satisfaction at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total mean score 4.56 (0.50) ns 4.53 (0.52) ns ns Women 4.47 (0.56) 4.43 (0.62) ns Men 4.59 (0.48) 4.58 (0.48) ns Factor 1, total mean score 4.45 (0.58) ns 4.41 (0.60) ns ns Women 4.27 (0.69) 4.75 (0.58) ns Men 4.47 (0.58) 4.78 (0.57) ns How well does your partner meet your needs? 61 (48.0) 4.25 (0.79) 55 (43.0) 4.32 (0.80) ns In general, how satisfied are you with your relationship? 69 (55.3) 4.46 (0.68) 71 (55.5) 4.43 (0.73) ns To what extent has your relationship met your original expectations? 66 (51.6) 4.41 (0.72) 64 (50.0) 4.31 (0.87) ns How many problems are there in your relationship? 1 (0.8) 4.61 (0.82) 1 (0.8) 4.64 (0.77) ns Factor 2, total mean score 4.76 (0.56) ns 4.77 (0.57) ns ns Women 4.72 (0.57) 4.75 (0.58) ns Men 4.77 (0.56) 4.78 (0.57) ns How often do you wish you had not become involved in this relationship? 1 (0.8) 4.71 (0.72) 1 (0.8) 4.73 (0.70) ns How much do you love your partner? 112 (86.8) 4.82 (0.54) 112 (86.8) 4.83 (0.53) ns Item content . Proportions of high satisfaction at T1, n (%)a . Mean score (SD) . P valueb . Proportions of high satisfaction at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total mean score 4.56 (0.50) ns 4.53 (0.52) ns ns Women 4.47 (0.56) 4.43 (0.62) ns Men 4.59 (0.48) 4.58 (0.48) ns Factor 1, total mean score 4.45 (0.58) ns 4.41 (0.60) ns ns Women 4.27 (0.69) 4.75 (0.58) ns Men 4.47 (0.58) 4.78 (0.57) ns How well does your partner meet your needs? 61 (48.0) 4.25 (0.79) 55 (43.0) 4.32 (0.80) ns In general, how satisfied are you with your relationship? 69 (55.3) 4.46 (0.68) 71 (55.5) 4.43 (0.73) ns To what extent has your relationship met your original expectations? 66 (51.6) 4.41 (0.72) 64 (50.0) 4.31 (0.87) ns How many problems are there in your relationship? 1 (0.8) 4.61 (0.82) 1 (0.8) 4.64 (0.77) ns Factor 2, total mean score 4.76 (0.56) ns 4.77 (0.57) ns ns Women 4.72 (0.57) 4.75 (0.58) ns Men 4.77 (0.56) 4.78 (0.57) ns How often do you wish you had not become involved in this relationship? 1 (0.8) 4.71 (0.72) 1 (0.8) 4.73 (0.70) ns How much do you love your partner? 112 (86.8) 4.82 (0.54) 112 (86.8) 4.83 (0.53) ns a Some missing responses, which explain the differences in the percentages. b Mean comparison between gender at T1. c Mean comparison between gender at T2. d Mean comparison between T1 and T2 and within gender (pair) at T1 and T2. Scores range from 1 (low satisfaction) to 5 (high satisfaction), items 4 and 5 are reverse scored. T1: time 1; T2: time 2. Open in new tab Table 2. Intimate relationships measured with the Swedish version of the relationship assessment scale: patients, N=128 (women n=36, men n=92) Item content . Proportions of high satisfaction at T1, n (%)a . Mean score (SD) . P valueb . Proportions of high satisfaction at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total mean score 4.56 (0.50) ns 4.53 (0.52) ns ns Women 4.47 (0.56) 4.43 (0.62) ns Men 4.59 (0.48) 4.58 (0.48) ns Factor 1, total mean score 4.45 (0.58) ns 4.41 (0.60) ns ns Women 4.27 (0.69) 4.75 (0.58) ns Men 4.47 (0.58) 4.78 (0.57) ns How well does your partner meet your needs? 61 (48.0) 4.25 (0.79) 55 (43.0) 4.32 (0.80) ns In general, how satisfied are you with your relationship? 69 (55.3) 4.46 (0.68) 71 (55.5) 4.43 (0.73) ns To what extent has your relationship met your original expectations? 66 (51.6) 4.41 (0.72) 64 (50.0) 4.31 (0.87) ns How many problems are there in your relationship? 1 (0.8) 4.61 (0.82) 1 (0.8) 4.64 (0.77) ns Factor 2, total mean score 4.76 (0.56) ns 4.77 (0.57) ns ns Women 4.72 (0.57) 4.75 (0.58) ns Men 4.77 (0.56) 4.78 (0.57) ns How often do you wish you had not become involved in this relationship? 1 (0.8) 4.71 (0.72) 1 (0.8) 4.73 (0.70) ns How much do you love your partner? 112 (86.8) 4.82 (0.54) 112 (86.8) 4.83 (0.53) ns Item content . Proportions of high satisfaction at T1, n (%)a . Mean score (SD) . P valueb . Proportions of high satisfaction at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total mean score 4.56 (0.50) ns 4.53 (0.52) ns ns Women 4.47 (0.56) 4.43 (0.62) ns Men 4.59 (0.48) 4.58 (0.48) ns Factor 1, total mean score 4.45 (0.58) ns 4.41 (0.60) ns ns Women 4.27 (0.69) 4.75 (0.58) ns Men 4.47 (0.58) 4.78 (0.57) ns How well does your partner meet your needs? 61 (48.0) 4.25 (0.79) 55 (43.0) 4.32 (0.80) ns In general, how satisfied are you with your relationship? 69 (55.3) 4.46 (0.68) 71 (55.5) 4.43 (0.73) ns To what extent has your relationship met your original expectations? 66 (51.6) 4.41 (0.72) 64 (50.0) 4.31 (0.87) ns How many problems are there in your relationship? 1 (0.8) 4.61 (0.82) 1 (0.8) 4.64 (0.77) ns Factor 2, total mean score 4.76 (0.56) ns 4.77 (0.57) ns ns Women 4.72 (0.57) 4.75 (0.58) ns Men 4.77 (0.56) 4.78 (0.57) ns How often do you wish you had not become involved in this relationship? 1 (0.8) 4.71 (0.72) 1 (0.8) 4.73 (0.70) ns How much do you love your partner? 112 (86.8) 4.82 (0.54) 112 (86.8) 4.83 (0.53) ns a Some missing responses, which explain the differences in the percentages. b Mean comparison between gender at T1. c Mean comparison between gender at T2. d Mean comparison between T1 and T2 and within gender (pair) at T1 and T2. Scores range from 1 (low satisfaction) to 5 (high satisfaction), items 4 and 5 are reverse scored. T1: time 1; T2: time 2. Open in new tab Sexual function The year before the MI event, the total score for the WSFQ was 45.92±6.55 and 48.59±4.96 (out of 65 possible scores) for women and men, respectively (P<0.05). The year after the MI event, the women reported a mean score of 45.08±7.25, while the men had a mean score of 47.10±5.16 (P<0.01). This implies that the women reported an unchanged sexual function the year after the MI event, while the men had decreased their sexual function (P<0.05). The only individual item score that changed between T1 and T2 for the female patients was that they less frequently reported ‘enjoyed sexual activity’ the year after the MI event (4.03±0.71 vs. 3.58±1.18, P<0.05). The male patients regarded ‘having sex’ as being a less important part of their life the year after the MI event (3.87±0.97 vs. 3.55±0.97, P<0.001). As for the women, they also ‘enjoyed sexual activity’ less frequently (4.45±0.88 vs. 4.16±0.91, P<0.001). Finally, the men were less satisfied ‘with the frequency of sexual activity’ (3.79±1.03 vs. 3.53±1.07, P<0.05), and felt that they more often ‘ejaculated too soon’ (3.52±0.77 vs. 3.69±0.85, P<0.05) during the past year compared to before the MI event, see Table 3. Table 3. Sexual function measured with the Swedish version of the Watts sexual function questionnaire: patients N=128 (women n=36, men n=92) Item . Proportions of scoring ‘always’ at T1, n (%)a . Mean score (SD) . P valueb . Proportions of scoring ‘always’ at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total score 0.05 0.01 Women 45.92 (6.56) 45.08 (7.25) ns Men 48.59 (4.96) 47.10 (5.16) 0.05 Sexual appetite (gender neutral) (1, 2, 5, 15, 16) To what extent is ‘having sex’ an important part of your life? ns ns Women 5 (16.7) 3.50 (0.90) 2 (6.5) 3.35 (0.76) ns Men 25 (28.1) 3.87 (0.97) 15 (17.0) 3.55 (0.97) 0.001 How frequently did you enjoy sexual activity? ns 0.05 Women 7 (22.6) 4.03 (0.71) 6 (19.4) 3.58 (1.18) 0.05 Men 53 (59.6) 4.45 (0.88) 36 (40.9) 4.16 (0.91) 0.001 How often did you have a desire for sex with partner? ns 0.05 Women 3 (9.7) 3.35 (0.66) 0 (0.0) 3.13 (0.62) ns Men 11 (12.5) 3.56 (0.91) 7 (8.0) 3.46 (0.82) ns To what extent did you feel satisfied after sexual activity? ns 0.01 Women 10 (32.3) 4.10 (0.75) 7 (23.3) 3.93 (0.83) ns Men 38 (42.7) 4.34 (0.74) 33 (33.9) 4.18 (0.88) ns How often were you satisfied with the frequency of sexual activity? 0.05 ns Women 7 (23.3) 3.87 (0.90) 6 (21.4) 3.68 (0.98) ns Men 21 (23.6) 3.79 (1.03) 12 (14.0) 3.53 (1.07) 0.05 Sexual expectations (gender neutral) (4, 6, 17) How frequently did you have daydreams or a fantasy about sex? ns 0.05 Women 0 (0.0) 2.23 (0.73) 0 (0.0) 2.16 (0.85) ns Men 3 (3.4) 2.64 (0.86) 2 (2.3) 2.67 (0.92) ns To what extent did you want sex more than your partner? 0.01 0.001 Women 1 (3.2) 2.19 (0.87) 0 (0.0) 2.13 (0.71) ns Men 6 (6.8) 2.95 (1.06) 4 (4.5) 2.94 (0.95) ns How frequently did you feel tense or nervous after a sexual experience? e 0.001 ns Women 23 (74.2) 4.68 (0.60) 20 (66.7) 4.47 (0.94) ns Men 54 (60.7) 4.51 (0.74) 56 (64.4) 4.48 (0.86) ns Sexual sensitiveness (10, 13, 14) How often did you feel pain or discomfort during sexual intercourse? e 0.05 0.001 Women 18 (58.1) 4.45 (0.72) 17 (56.7) 4.33 (0.84) ns How frequently did you lose a hard erection before ‘coming’ (ejaculating)?e Men 19 (21.6) 2.71 (0.84) 9 (10.5) 3.59 (0.83) ns How often were you able to reach a climax (come)? Women 5 (16.1) 3.77 (0.80) 0.01 5 (16.7) 3.67 (0.99) 0.001 ns How frequently did you have other problems in ‘coming’ (ejaculating)? Men 33 (37.1) 4.16 (0.86) 26 (29.9) 3.97 (0.88) ns To what extent was it important for you to reach a climax (come)? ns 0.01 Women 2 (6.7) 3.30 (1.09) 3 (10.3) 3.38 (0.94) ns How often did you ejaculate through a flaccid penis? Men 1 (1.1) 4.56 (0.71) 0 (0.0) 4.57 (0.72) ns Sexual ability (7, 12) During your last sexual experience, to what extent were you aware of wetness in your vagina as you became sexually excited? 0.01 0.01 Women 11 (36.7) 3.77 (1.28) 7 (22.6) 3.52 (1.15) ns How often did you wake up with erection in the morning? Men 2 (2.2) 2.71 (0.84) 2 (2.3) 2.70 (0.83) ns As sexual excitement became more intense, how often were you aware of throbbing sensations in your vagina? 0.001 ns Women 2 (6.5) 3.16 (1.00) 3 (10.3) 3.21 (1.08) ns How often did you feel that you ‘came’ (ejaculated) too soon? Men 1 (1.1) 3.52 (0.77) 0 (0.0) 3.69 (0.85) 0.05 Item . Proportions of scoring ‘always’ at T1, n (%)a . Mean score (SD) . P valueb . Proportions of scoring ‘always’ at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total score 0.05 0.01 Women 45.92 (6.56) 45.08 (7.25) ns Men 48.59 (4.96) 47.10 (5.16) 0.05 Sexual appetite (gender neutral) (1, 2, 5, 15, 16) To what extent is ‘having sex’ an important part of your life? ns ns Women 5 (16.7) 3.50 (0.90) 2 (6.5) 3.35 (0.76) ns Men 25 (28.1) 3.87 (0.97) 15 (17.0) 3.55 (0.97) 0.001 How frequently did you enjoy sexual activity? ns 0.05 Women 7 (22.6) 4.03 (0.71) 6 (19.4) 3.58 (1.18) 0.05 Men 53 (59.6) 4.45 (0.88) 36 (40.9) 4.16 (0.91) 0.001 How often did you have a desire for sex with partner? ns 0.05 Women 3 (9.7) 3.35 (0.66) 0 (0.0) 3.13 (0.62) ns Men 11 (12.5) 3.56 (0.91) 7 (8.0) 3.46 (0.82) ns To what extent did you feel satisfied after sexual activity? ns 0.01 Women 10 (32.3) 4.10 (0.75) 7 (23.3) 3.93 (0.83) ns Men 38 (42.7) 4.34 (0.74) 33 (33.9) 4.18 (0.88) ns How often were you satisfied with the frequency of sexual activity? 0.05 ns Women 7 (23.3) 3.87 (0.90) 6 (21.4) 3.68 (0.98) ns Men 21 (23.6) 3.79 (1.03) 12 (14.0) 3.53 (1.07) 0.05 Sexual expectations (gender neutral) (4, 6, 17) How frequently did you have daydreams or a fantasy about sex? ns 0.05 Women 0 (0.0) 2.23 (0.73) 0 (0.0) 2.16 (0.85) ns Men 3 (3.4) 2.64 (0.86) 2 (2.3) 2.67 (0.92) ns To what extent did you want sex more than your partner? 0.01 0.001 Women 1 (3.2) 2.19 (0.87) 0 (0.0) 2.13 (0.71) ns Men 6 (6.8) 2.95 (1.06) 4 (4.5) 2.94 (0.95) ns How frequently did you feel tense or nervous after a sexual experience? e 0.001 ns Women 23 (74.2) 4.68 (0.60) 20 (66.7) 4.47 (0.94) ns Men 54 (60.7) 4.51 (0.74) 56 (64.4) 4.48 (0.86) ns Sexual sensitiveness (10, 13, 14) How often did you feel pain or discomfort during sexual intercourse? e 0.05 0.001 Women 18 (58.1) 4.45 (0.72) 17 (56.7) 4.33 (0.84) ns How frequently did you lose a hard erection before ‘coming’ (ejaculating)?e Men 19 (21.6) 2.71 (0.84) 9 (10.5) 3.59 (0.83) ns How often were you able to reach a climax (come)? Women 5 (16.1) 3.77 (0.80) 0.01 5 (16.7) 3.67 (0.99) 0.001 ns How frequently did you have other problems in ‘coming’ (ejaculating)? Men 33 (37.1) 4.16 (0.86) 26 (29.9) 3.97 (0.88) ns To what extent was it important for you to reach a climax (come)? ns 0.01 Women 2 (6.7) 3.30 (1.09) 3 (10.3) 3.38 (0.94) ns How often did you ejaculate through a flaccid penis? Men 1 (1.1) 4.56 (0.71) 0 (0.0) 4.57 (0.72) ns Sexual ability (7, 12) During your last sexual experience, to what extent were you aware of wetness in your vagina as you became sexually excited? 0.01 0.01 Women 11 (36.7) 3.77 (1.28) 7 (22.6) 3.52 (1.15) ns How often did you wake up with erection in the morning? Men 2 (2.2) 2.71 (0.84) 2 (2.3) 2.70 (0.83) ns As sexual excitement became more intense, how often were you aware of throbbing sensations in your vagina? 0.001 ns Women 2 (6.5) 3.16 (1.00) 3 (10.3) 3.21 (1.08) ns How often did you feel that you ‘came’ (ejaculated) too soon? Men 1 (1.1) 3.52 (0.77) 0 (0.0) 3.69 (0.85) 0.05 a Some missing responses, which explain the differences in the percentages. b Mean comparison between gender at T1. c Mean comparison between gender at T2. d Mean comparison within gender (pair) at T1 and T2. e Items 10, 13 and 17 are reverse scored for men and items 10 and 17 for women, respectively, i.e. proportions of scoring ‘never’. T1: time 1; T2: time 2. Open in new tab Table 3. Sexual function measured with the Swedish version of the Watts sexual function questionnaire: patients N=128 (women n=36, men n=92) Item . Proportions of scoring ‘always’ at T1, n (%)a . Mean score (SD) . P valueb . Proportions of scoring ‘always’ at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total score 0.05 0.01 Women 45.92 (6.56) 45.08 (7.25) ns Men 48.59 (4.96) 47.10 (5.16) 0.05 Sexual appetite (gender neutral) (1, 2, 5, 15, 16) To what extent is ‘having sex’ an important part of your life? ns ns Women 5 (16.7) 3.50 (0.90) 2 (6.5) 3.35 (0.76) ns Men 25 (28.1) 3.87 (0.97) 15 (17.0) 3.55 (0.97) 0.001 How frequently did you enjoy sexual activity? ns 0.05 Women 7 (22.6) 4.03 (0.71) 6 (19.4) 3.58 (1.18) 0.05 Men 53 (59.6) 4.45 (0.88) 36 (40.9) 4.16 (0.91) 0.001 How often did you have a desire for sex with partner? ns 0.05 Women 3 (9.7) 3.35 (0.66) 0 (0.0) 3.13 (0.62) ns Men 11 (12.5) 3.56 (0.91) 7 (8.0) 3.46 (0.82) ns To what extent did you feel satisfied after sexual activity? ns 0.01 Women 10 (32.3) 4.10 (0.75) 7 (23.3) 3.93 (0.83) ns Men 38 (42.7) 4.34 (0.74) 33 (33.9) 4.18 (0.88) ns How often were you satisfied with the frequency of sexual activity? 0.05 ns Women 7 (23.3) 3.87 (0.90) 6 (21.4) 3.68 (0.98) ns Men 21 (23.6) 3.79 (1.03) 12 (14.0) 3.53 (1.07) 0.05 Sexual expectations (gender neutral) (4, 6, 17) How frequently did you have daydreams or a fantasy about sex? ns 0.05 Women 0 (0.0) 2.23 (0.73) 0 (0.0) 2.16 (0.85) ns Men 3 (3.4) 2.64 (0.86) 2 (2.3) 2.67 (0.92) ns To what extent did you want sex more than your partner? 0.01 0.001 Women 1 (3.2) 2.19 (0.87) 0 (0.0) 2.13 (0.71) ns Men 6 (6.8) 2.95 (1.06) 4 (4.5) 2.94 (0.95) ns How frequently did you feel tense or nervous after a sexual experience? e 0.001 ns Women 23 (74.2) 4.68 (0.60) 20 (66.7) 4.47 (0.94) ns Men 54 (60.7) 4.51 (0.74) 56 (64.4) 4.48 (0.86) ns Sexual sensitiveness (10, 13, 14) How often did you feel pain or discomfort during sexual intercourse? e 0.05 0.001 Women 18 (58.1) 4.45 (0.72) 17 (56.7) 4.33 (0.84) ns How frequently did you lose a hard erection before ‘coming’ (ejaculating)?e Men 19 (21.6) 2.71 (0.84) 9 (10.5) 3.59 (0.83) ns How often were you able to reach a climax (come)? Women 5 (16.1) 3.77 (0.80) 0.01 5 (16.7) 3.67 (0.99) 0.001 ns How frequently did you have other problems in ‘coming’ (ejaculating)? Men 33 (37.1) 4.16 (0.86) 26 (29.9) 3.97 (0.88) ns To what extent was it important for you to reach a climax (come)? ns 0.01 Women 2 (6.7) 3.30 (1.09) 3 (10.3) 3.38 (0.94) ns How often did you ejaculate through a flaccid penis? Men 1 (1.1) 4.56 (0.71) 0 (0.0) 4.57 (0.72) ns Sexual ability (7, 12) During your last sexual experience, to what extent were you aware of wetness in your vagina as you became sexually excited? 0.01 0.01 Women 11 (36.7) 3.77 (1.28) 7 (22.6) 3.52 (1.15) ns How often did you wake up with erection in the morning? Men 2 (2.2) 2.71 (0.84) 2 (2.3) 2.70 (0.83) ns As sexual excitement became more intense, how often were you aware of throbbing sensations in your vagina? 0.001 ns Women 2 (6.5) 3.16 (1.00) 3 (10.3) 3.21 (1.08) ns How often did you feel that you ‘came’ (ejaculated) too soon? Men 1 (1.1) 3.52 (0.77) 0 (0.0) 3.69 (0.85) 0.05 Item . Proportions of scoring ‘always’ at T1, n (%)a . Mean score (SD) . P valueb . Proportions of scoring ‘always’ at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total score 0.05 0.01 Women 45.92 (6.56) 45.08 (7.25) ns Men 48.59 (4.96) 47.10 (5.16) 0.05 Sexual appetite (gender neutral) (1, 2, 5, 15, 16) To what extent is ‘having sex’ an important part of your life? ns ns Women 5 (16.7) 3.50 (0.90) 2 (6.5) 3.35 (0.76) ns Men 25 (28.1) 3.87 (0.97) 15 (17.0) 3.55 (0.97) 0.001 How frequently did you enjoy sexual activity? ns 0.05 Women 7 (22.6) 4.03 (0.71) 6 (19.4) 3.58 (1.18) 0.05 Men 53 (59.6) 4.45 (0.88) 36 (40.9) 4.16 (0.91) 0.001 How often did you have a desire for sex with partner? ns 0.05 Women 3 (9.7) 3.35 (0.66) 0 (0.0) 3.13 (0.62) ns Men 11 (12.5) 3.56 (0.91) 7 (8.0) 3.46 (0.82) ns To what extent did you feel satisfied after sexual activity? ns 0.01 Women 10 (32.3) 4.10 (0.75) 7 (23.3) 3.93 (0.83) ns Men 38 (42.7) 4.34 (0.74) 33 (33.9) 4.18 (0.88) ns How often were you satisfied with the frequency of sexual activity? 0.05 ns Women 7 (23.3) 3.87 (0.90) 6 (21.4) 3.68 (0.98) ns Men 21 (23.6) 3.79 (1.03) 12 (14.0) 3.53 (1.07) 0.05 Sexual expectations (gender neutral) (4, 6, 17) How frequently did you have daydreams or a fantasy about sex? ns 0.05 Women 0 (0.0) 2.23 (0.73) 0 (0.0) 2.16 (0.85) ns Men 3 (3.4) 2.64 (0.86) 2 (2.3) 2.67 (0.92) ns To what extent did you want sex more than your partner? 0.01 0.001 Women 1 (3.2) 2.19 (0.87) 0 (0.0) 2.13 (0.71) ns Men 6 (6.8) 2.95 (1.06) 4 (4.5) 2.94 (0.95) ns How frequently did you feel tense or nervous after a sexual experience? e 0.001 ns Women 23 (74.2) 4.68 (0.60) 20 (66.7) 4.47 (0.94) ns Men 54 (60.7) 4.51 (0.74) 56 (64.4) 4.48 (0.86) ns Sexual sensitiveness (10, 13, 14) How often did you feel pain or discomfort during sexual intercourse? e 0.05 0.001 Women 18 (58.1) 4.45 (0.72) 17 (56.7) 4.33 (0.84) ns How frequently did you lose a hard erection before ‘coming’ (ejaculating)?e Men 19 (21.6) 2.71 (0.84) 9 (10.5) 3.59 (0.83) ns How often were you able to reach a climax (come)? Women 5 (16.1) 3.77 (0.80) 0.01 5 (16.7) 3.67 (0.99) 0.001 ns How frequently did you have other problems in ‘coming’ (ejaculating)? Men 33 (37.1) 4.16 (0.86) 26 (29.9) 3.97 (0.88) ns To what extent was it important for you to reach a climax (come)? ns 0.01 Women 2 (6.7) 3.30 (1.09) 3 (10.3) 3.38 (0.94) ns How often did you ejaculate through a flaccid penis? Men 1 (1.1) 4.56 (0.71) 0 (0.0) 4.57 (0.72) ns Sexual ability (7, 12) During your last sexual experience, to what extent were you aware of wetness in your vagina as you became sexually excited? 0.01 0.01 Women 11 (36.7) 3.77 (1.28) 7 (22.6) 3.52 (1.15) ns How often did you wake up with erection in the morning? Men 2 (2.2) 2.71 (0.84) 2 (2.3) 2.70 (0.83) ns As sexual excitement became more intense, how often were you aware of throbbing sensations in your vagina? 0.001 ns Women 2 (6.5) 3.16 (1.00) 3 (10.3) 3.21 (1.08) ns How often did you feel that you ‘came’ (ejaculated) too soon? Men 1 (1.1) 3.52 (0.77) 0 (0.0) 3.69 (0.85) 0.05 a Some missing responses, which explain the differences in the percentages. b Mean comparison between gender at T1. c Mean comparison between gender at T2. d Mean comparison within gender (pair) at T1 and T2. e Items 10, 13 and 17 are reverse scored for men and items 10 and 17 for women, respectively, i.e. proportions of scoring ‘never’. T1: time 1; T2: time 2. Open in new tab Both at T1 and T2, the male patients reported higher scores compared to their female counterparts when it comes to ‘wanting to have sex more than their partner’ (T1: 2.95±1.06 vs. 2.19±0.87, respectively, P<0.01; T2: 2.94±0.95 vs. 2.13±0.71, P<0.001). The men were also less pleased with ‘how often they were satisfied with the frequency of sexual activity’ compared to the women (3.79±1.03 vs. 3.87±0.90, P<0.05) at T1, but one year after the MI event no statistically significant differences remained (3.53±1.07 vs. 3.68±0.98, ns). The women reported that they more frequently ‘felt tense or nervous after a sexual experience’ (4.68±0.60 vs. 4.51±0.74, P<0.001) at T1, but at the follow-up there was no statistically significant difference in scoring on this item between genders (4.47±0.94 vs.4.48±0.86, ns). The year after the MI event, the men reported that they ‘more frequently enjoyed sexual activity’ compared to their female counterparts (4.16±0.91 vs. 3.58±1.18, P<0.05), they also more often ‘had a desire for sex with their partner’ (3.46±0.82 vs. 3.13±0.62, P<0.05), and ‘felt satisfied after sexual activity’ (4.18±0.88 vs. 3.93±0.83, P<0.01), see Table 3. At both T1 and T2, the lowest individual scoring for the women was reported on the item ‘to what extent did you want sex more than your partner’ (2.19±0.87 and 2.13±0.71, T1 and T2, respectively, ns), while the men scored lowest on the item ‘how frequently did you have daydreams or a fantasy about sex’ (2.64±0.86 and 2.67±0.92, T1 and T2, respectively, ns). The highest scoring was by the women given the reversed item ‘how frequently did you feel tense or nervous after a sexual experience’ with a mean score of 4.68±0.60 and 4.47±0.94, for T1 and T2, respectively (ns). The men scored highest on the item ‘how often did you ejaculate through a flaccid penis’ on both occasions (4.56±0.71 and 4.57±0.72, T1 and T2, respectively, ns), see Table 3. Discussion The results of our study corroborate and extend previous findings about how intimate relationships, including sexuality, constitute an important and meaningful context in partnered patients’ wellbeing following a first MI. We found that patients’ ratings of their general intimate relationship satisfaction were high, both before, and the year after the MI event (Table 2). This is congruent with earlier published results from our research group seen from the perspective of the partners.21 In contrast, previous studies using in-depth interviews have found negative influences on the marital and intimate relationship following an MI.28,29 A systematic literature review on partner relationship found – even though most couples experienced great distress following being afflicted with an MI – that they reported that the disease had brought them closer together.30 This is in line with our result concerning highly scored satisfaction, stable over time, among the patients, concerning terms of expectations and satisfaction of needs, and love and devotion in their intimate relationship (Table 2). Our patients tended to decrease their sexual activity the year following the MI, with a decrease of 6%; but the difference was not statistically significant. Nevertheless, the men reported that having sex was a less important part of their life, and they were less satisfied with the frequency of sexual activity the year following the MI. The men also described a decreased sexual function in general, and felt that they had more often ejaculated prematurely during the past year compared to before the MI event (Table 3). This is of the utmost importance because a recent meta-analysis showed that the presence of erectile dysfunction in MI patients increases the risk of future cardiovascular events, MI, cerebrovascular events, as well as all-cause mortality.31 A previous study has found that rates of sexual dysfunction also among women with cardiovascular disease are twice as high as those in the general population.32 Our findings indicate that the women had a lower sexual function both the year before the MI, as well as the subsequent year, compared to the men. However, the women’s sexual function was stable over time (Table 3). One explanation for this could be the higher prevalence of tiredness, sleep disturbances and general anxiety described in the women in comparison with the men, possibly affecting the women’s sexual desire (Table 1). However, both men and women reported that they enjoyed sexual activity less frequently (Table 3). Also, a recent integrative literature review showed that many patients present with sexual dysfunction after an MI event, often as an adverse effect of medication, or they become afraid of resuming sexual life, fearing that some adverse events such as chest pain, a recurrent MI or sudden death will occur.33 Men and women are often different in their arousal patterns. Typically, women will focus on feeling ‘desired’ or ‘attractive’ to their man, while typically men will focus on feeling ‘invited’ or ‘welcomed’ to engage in sex.34 Sexual confidence, then, is more about function for men while women’s confidence may involve trust, security and caring. This difference in sexual function and arousal patterns between men and women points out the importance of taking into consideration gender aspects when counselling patients after an MI event. Furthermore, others have described that men, to a greater extent than women, want and report receiving more information about sexual activity.35 The importance of timely and tailored information, as well as appropriate referrals for sexual counselling, is vital. Still, sexuality in relation to heart disease is not routinely discussed in the CR setting,16,19,36 leaving the patients with limited knowledge about sexual health and sexual activity.37 This lack of information is concurrent with our findings, with just one third of the patients reporting that the healthcare professionals had addressed sexuality as a topic during the CR programme. It is common for healthcare professionals to feel uncomfortable in initiating a dialogue about sexuality related to lack of knowledge, discomfort in addressing the subject and a feeling of invading the privacy of patients, in addition to personal beliefs, attitudes and behaviour.38 However, as sexual function is an important component in quality of life and activities of daily living, healthcare professionals should receive training in addressing sexuality in the treatment of post-MI patients.1,14 General suggestions to the patient may include being well rested at the time of sexual activity, avoiding unfamiliar surroundings and partners in order to minimize stress during sexual activity, avoiding heavy meals or alcohol before sexual activity, and using a position that does not restrict respiration.39–41 Hartmann and Burkart42 maintained that a short patient questionnaire is an excellent aid for patients and healthcare professionals for initiating discussions about sexuality, and it has been suggested26 that the WSFQ used in our study can form the basis for such a communication between patients with heart diseases and healthcare professionals. A great advantage of this questionnaire is that it has both gender and non-gender-specific questions. The strengths of the present study are a representative sample nationally and a longitudinal design examining ratings of sexual functioning and intimate relationships both before and one year post-MI. This study also has some limitations. It should be noted that the patients answered the first questionnaire a few weeks after their MI, and were at that point asked retrospectively to assess their experiences one year prior to the MI event, which may reflect recall bias. The newly experienced MI event may have affected the assessment of the intimate relationship at T1, and this potential bias could explain the stable relationship ratings over time in our study. However, it is not surprising that the majority of patients rated their intimate relationship as very good, as most of them had lived with their current partner for many years. The findings presented are based on those who agreed to participate in this study and therefore may reflect attribution bias. This study is also limited by the rather low sample size and the attrition rates over a one-year period (from T1 to T2), with 71% of the patients who participated at T1 also participating at T2. However, no statistically significant differences were found between patients who participated at both times as compared to those who only took part on the first occasion with regard to background characteristics, self-rated sexual health, or total RAS and WSFQ ratings at T1. Finally, we did not ask questions about specific content in the sexual counselling with healthcare professionals after the MI – or who had initiated such a conversation – just if a dialogue had occurred and how the patients rated its content. Conclusions Partnered first-time MI patients continue to be sexually active the subsequent year, and are highly satisfied with their intimate relationship. While the MI event itself seems to have a more negative impact on men’s sexual functioning than women’s, the women still rate their sexual function lower in comparison. Sexuality is not routinely discussed in the CR setting, suggesting that more attention to this subject among healthcare professionals is needed. Acknowledgement The authors would like to thank the participants for taking part in the study, and the SAMMI study group for fruitful collaboration during the project. Conflict of interest statement The authors have no conflicts of interest to declare. Funding The study was funded by the Strategic Research Programme in Health Care Sciences (SFO-V), ‘Bridging Research and Practice for Better Health’, Karolinska Institutet Stockholm and Umeå University, Sweden. Implications for practice Troublesome symptoms during intercourse are common and should be addressed by the healthcare professionals. Sexual appetite, expectations, sensitiveness and ability may differ between men and women and change over time, thus assessment and open discussion regarding these issues can help promote relationship satisfaction post-myocardial infarction. Sexuality is not routinely discussed in the cardiac rehabilitation setting after a first myocardial infarction, suggesting that more attention to this subject among healthcare professionals is needed. The use of the Watts sexual function questionnaire could be a helpful tool to discuss sexuality with patients. Such a discussion may open up for tailored education including both gender and non-gender-specific sexual issues. References 1 Steinke E E , Jaarsma T, Barnasan S Aet al. . 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) . Eur Heart J 2013 ; 34 : 3217 – 3235 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Perk J , De Backer G, Gohlke Het al. . The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts)*. Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR) . Eur Heart J 2012 ; 33 : 1635 – 1701 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Savage P , Sanderson B, Brown Tet al. . Clinical research in cardiac rehabilitation and secondary prevention . J Cardiopulm Rehabil 2011 ; 31 : 333 – 341 . Google Scholar Crossref Search ADS WorldCat 4 Shepherd C , White A . Cardiac rehabilitation and quality of life: a systematic review . Int J Nurs Stud 2012 ; 49 : 755 – 771 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Waltz M . Marital context and postinfarction quality of life: is it social support or something more? Soc Sci Med 1986 ; 22 : 791 – 805 . Google Scholar Crossref Search ADS PubMed WorldCat 6 King K B , Reis H T . Marriage and long-term survival after coronary artery bypass grafting . Health Psychology 2012 ; 31 : 55 – 62 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Gorge G , Fluchter S, Kirstein Met al. . Sex, erectile dysfunction, and the heart: a growing problem . Herz 2003 ; 28 : 284 – 290 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Steinke E E , Wright D W . The role of sexual satisfaction, age, and cardiac risk factors in the reduction of post-MI anxiety . Eur J Cardiovasc Nurs 2006 ; 5 : 190 – 196 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Timmins F , Kaliszer M . Information needs of myocardial infarction patients . Eur J Cardiovasc Nurs 2003 ; 2 : 57 – 65 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Lindau S T , Schumm L P, Laumann E Oet al. . A study of sexuality and health among older adults in the United States . N Engl J Med 2007 ; 357 : 762 – 774 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Lindau S T , Gavrilova N Sex, health, and years of sexually active life gained due to good health: Evidence from two US populations based cross sectional surveys of ageing . BMJ 2010 ; 340 : c810 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Lindau S T , Tang H, Gomero Aet al. . Sexuality among middle-aged and older adults with diagnosed and undiagnosed diabetes: A national, population-based study . Diabetes Care 2010 ; 33 : 2202 – 2210 . Google Scholar Crossref Search ADS PubMed WorldCat 13 Lindau S , Surawska H, Paice Jet al. . Communication about sexuality and intimacy in couples affected by lung cancer and their clinical-care providers . Psycho oncology 2011 ; 20 : 179 – 185 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Levine G N , Steinke E E, Bakaeen F Get al. . Sexual activity and cardiovascular disease. A scientific statement from the American Heart Association . Circulation 2012 ; 125 : 1058 – 1072 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Balady G , Williams M, Ades Pet al. . Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation . Circulation 2007 ; 115 : 2675 – 2682 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Ivarsson B , Fridlund B, Sjöberg T . Information from healthcare professionals about sexual function and coexistence after myocardial infarction: a Swedish national survey . Heart & Lung 2009 ; 38 : 330 – 335 . Google Scholar Crossref Search ADS PubMed WorldCat 17 Jaarsma T , Strömberg A, Fridlund Bet al. . Sexual counselling of cardiac patients: Nurses perception of practice, responsibility and confidence . Eur J Cardiovasc Nurs 2010 ; 9 : 24 – 29 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Nicolai M P , Both S, Liem S Set al. . Discussing sexual function in the cardiology practice . Clin Res Cardiol 2013 ; 102 : 329 – 336 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Tessler-Lindau S , Abramsohn E, Gosch Ket al. . Patterns and loss of sexual activity in the year following hospitalization for myocardial infarction: a U.S. national, multi-site observational study . Am J Cardiol 2012 ; 109 : 1439 – 1444 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Laumann E O , Paik A, Rosen R C . Sexual dysfunction in the United States: Prevalence and predictors . JAMA 1999 ; 261 : 537 – 544 . Google Scholar Crossref Search ADS WorldCat 21 Fransson E I , Arenhall E, Steinke E Eet al. . Perceptions of intimate relationships in partners before and after a patient’s myocardial infarction . J Clin Nurs 2014 ; 23 : 2196 – 2204 . Google Scholar Crossref Search ADS PubMed WorldCat 22 World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects . JAMA 2013 ; 310 : 2191 – 2194 . Crossref Search ADS PubMed WorldCat 23 Rask M , Malm D, Kristofferzon Met al. . Validity and reliability of a Swedish version of the Relationship Assessment Scale (RAS) – a pilot study . Can J Cardiovasc Nurs 2010 ; 20 : 16 – 21 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 24 Hendrick S S , Dicke A, Hendrick C . The relationship assessment scale . J Soc Pers Rel 1988 ; 15 : 137 – 142 . Google Scholar Crossref Search ADS WorldCat 25 Brislin R W . Back-translation for cross-cultural research . J Cross-Cult Psych 1970 ; 1 : 185 – 216 . Google Scholar Crossref Search ADS WorldCat 26 Kristofferzon M-L , Johansson I, Brännström Met al. . and the SAMMI-study group. Evaluation of a Swedish version of the Watts Sexual Function Questionnaire (WSFQ) in persons with heart disease: A pilot study . Eur J Cardiovasc Nurs 2010 ; 9 : 168 – 174 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Watts R J . Sexual functioning, health beliefs, and compliance with high blood pressure medications . Nurs Res 1982 ; 31 : 278 – 283 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Arenhall E , Kristofferzon M-L, Fridlund Bet al. . The female partners’ experiences of intimate relationship after a first myocardial infarction . J Clin Nurs 2011 ; 20 : 1677 – 1684 . Google Scholar Crossref Search ADS PubMed WorldCat 29 Arenhall E , Kristofferzon M L, Fridlund Bet al. . The male partners’ experiences of the intimate relationships after a first myocardial infarction . Eur J Cardiovasc Nurs 2011 ; 10 ; 108 – 114 . Google Scholar Crossref Search ADS PubMed WorldCat 30 Dalteg T , Benzein E, Fridlund Bet al. . Cardiac disease and its consequences on the partner relationship: a systematic review . Eur J Cardiovasc Nurs 2011 ; 10 : 140 – 149 . Google Scholar Crossref Search ADS PubMed WorldCat 31 Vlachopoulos C V , Terentes-Printzios D G, Ioakeimidis N Ket al. . Prediction of cardiovascular events and all-cause mortality with erectile dysfunction: A systematic review and meta-analysis of cohort studies . Circ Cardiovasc Qual Outcomes 2013 ; 6 : 99 – 109 . Google Scholar Crossref Search ADS PubMed WorldCat 32 Kriston L , Gunzler C, Agyemang Aet al. .; SPARK Study Group. Effect of sexual function on health-related quality of life mediated by depressive symptoms in cardiac rehabilitation: findings of the SPARK project in 493 patients . J Sex Med 2010 ; 7 : 2044 – 2055 . Google Scholar Crossref Search ADS PubMed WorldCat 33 Bispo G S , de Lima Lopes J, de Barros ALB L . Cardiovascular changes resulting from sexual activity and sexual dysfunction after myocardial infarction: integrative review . J Clin Nurs 2013 ; 22 : 3522 – 3531 . Google Scholar Crossref Search ADS PubMed WorldCat 34 Fisher H E , Aron A, Mashek Det al. . Defining the brain systems of lust, romantic attraction, and attachment . Arch Sex Behav 2002 ; 31 : 413 – 419 . Google Scholar Crossref Search ADS PubMed WorldCat 35 Stewart D E , Abbey S E, Shnek Z Met al. . Gender differences in health information needs and decisional preferences in patients recovering from an acute ischemic coronary event . Psychosom Med 2004 ; 66 : 42 – 48 . Google Scholar Crossref Search ADS PubMed WorldCat 36 Abramsohn E M , Decker C, Garavalia Bet al. . “I’m not just a heart, I’m a whole person here”: A qualitative study to improve sexual outcomes in women with myocardial infarction . J Am Heart Assoc 2013 ; 2 : e000199 . Google Scholar Crossref Search ADS PubMed WorldCat 37 Brännström M , Kristofferzon M L, Ivarsson Bet al. . Sexual knowledge in patients with a myocardial infarction and their partners . J Cardiovasc Nurs 2014 ; 29 : 332 – 339 . Google Scholar Crossref Search ADS PubMed WorldCat 38 Steinke E E , Mosack V, Barnason Set al. . Progress in sexual counseling by cardiac nurses 1994 to 2011 . Heart & Lung 2011 ; 40 : e15 – e24 . Google Scholar Crossref Search ADS PubMed WorldCat 39 Akdolun N , Terakye G . Sexual problems before and after myocardial infarction: patients’ needs for information . Rehabil Nurs 2001 ; 26 : 152 – 158 . Google Scholar Crossref Search ADS PubMed WorldCat 40 Steinke E E , Swan J . Effectiveness of a videotape for sexual counselling after myocardial infarction . Res Nurs Health 2004 ; 27 : 269 – 280 . Google Scholar Crossref Search ADS PubMed WorldCat 41 Steinke E E , Mosack V, Wright D Wet al. . Risk factors as predictors of sexual activity in heart failure . Dimens Crit Care Nurs 2009 ; 28 : 123 – 129 . Google Scholar Crossref Search ADS PubMed WorldCat 42 Hartmann U , Burkart M . Erectile dysfunctions in patient–physician communication: optimized strategies for addressing sexual issues and the benefit of using a patient questionnaire . J Sex Med 2007 ; 4 : 38 – 46 . Google Scholar Crossref Search ADS PubMed WorldCat © The European Society of Cardiology 2015 This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The European Society of Cardiology 2015 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardiovascular Nursing Oxford University Press

Intimate relationships and sexual function in partnered patients in the year before and one year after a myocardial infarction: A longitudinal study

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Oxford University Press
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Copyright © 2022 European Society of Cardiology
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1474-5151
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1873-1953
DOI
10.1177/1474515115571061
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Abstract

Abstract Background Intimate relationships and sexuality are essential to an individual’s health and longevity after a myocardial infarction (MI). Aims To explore and compare partnered first-time MI patients’ ratings of intimate relationship satisfaction and sexual function before the MI as compared to one year after the event. Methods Longitudinal study with 92 men and 36 women, aged 62.4±9.3 years. Self-reported data was collected one year before, and one year after, the MI. Results The majority were sexually active before (86%) as well as after (80%) their MI (ns). High satisfaction was reported with intimate relationships, which were stable over time (Relationship assessment scale score 4.56±0.50 and 4.53±0.52, respectively, ns). No significant differences in intimate relationships between genders were found. Women reported lower ratings in their sexual function than men before the MI (Watts sexual function score 45.92±6.55 and 48.59±4.96, respectively, P<0.05). The year after the event, women described an unchanged sexual function (45.08±7.25), while men (47.10±5.16) had decreased theirs (P<0.05). Both female and male patients enjoyed sexual activity less frequently the subsequent year. Men regarded having sex as being less important in their lives, were less satisfied with the frequency of sexual activity, and felt that they more often ejaculated prematurely the year after the MI. Conclusions Partnered first-time MI patients continue to be sexually active the year after the event, and are highly satisfied with their intimate relationship. While the MI event seems to have a more negative impact on men’s sexual functioning than women’s, the women still rate their sexual function lower in comparison. Gender, myocardial infarction, relationship assessment scale, sexual counselling, Watts sexual function questionnaire Introduction After a myocardial infarction (MI), patients often have to deal with consequences of the disease, or its treatment, on their everyday life and functioning, which may lead to impaired quality of life.1 Therefore, cardiac rehabilitation (CR) should be offered to all patients after a cardiac event to help them cope with their new life situation.2 This multifaceted programme will increase survival, decrease subsequent cardiac events, and improve quality of life.3,4 Intimate relationships including dyadic quality, spousal satisfaction and intimacy are essential to people’s health and longevity after a cardiac event.5,6 Sexual functioning in married life has consequently become an important component when measuring quality of life in clinical research in patients with heart disease.7–9 Sexually inactive older adults – as well as those with other chronic or life-threatening illnesses – also value sexuality as an important part of life and health.10–13 Identification of sexual problems has therefore been recommended as a component of psychosocial management in CR programmes.14,15 However, few of the healthcare professionals working with cardiovascular patients are addressing questions related to the intimate relationship on a regular basis.16–18 Potential explanations for the lack of attention towards sexual matters are mainly due to a lack of sexual knowledge,16–18 time constraints,18 a belief that that their patients could be upset, embarrassed or anxious,17 or lack of initiative on the part of the patient;18 with the latter also being reported from the patient’s perspective.19 Lack of sexual counselling during the CR has been found to be associated with loss of sexual activity the year after the MI.19 Approximately 45% of couples at a given time suffer sexual problems.20 When our research group investigated partners’ intimate relationship both before and after the patients’ MI, we found that they were highly satisfied with their relationship.21 However, more evidence is needed to obtain a better understanding of patients’ concerns and to facilitate marital communication and satisfaction related to an acute MI event. Therefore, the aim of this longitudinal study was to: explore and compare partnered first-time MI patients’ ratings of intimate relationship satisfaction and sexual function before the MI as compared to one year after the event; explore if any gender differences exist in intimate relationships and sexual functions; and describe if any sexual counselling had been received in the CR programme and the perceived quality of the same. Methods Design, setting and participants This multicentre study is a substudy of sexual and marital life in a myocardial infarction (SAMMI) context project (www.sammi.dinstudio.se). A descriptive and exploratory study design was used with data from one year before the MI event (retrospectively collected approximately 3 weeks after the MI) and the subsequent year after the event. This national survey study enrolled participants from 13 hospitals in Sweden: four university hospitals and nine county hospitals. The hospitals were selected by a stratified sampling method based on a divergent geographical location and type of hospital. Patients with a first time MI who had been hospitalized at one of the participating hospitals were consecutively recruited over a period of 20 months in 2007–2009, which ended with a one-year follow-up from 2008 to 2010. The inclusion criteria were as follows: the patient met criteria for a first MI; was admitted, and planned to attend the follow-up at a cardiac outpatient programme at the hospital; lived in a relationship for at least one year. The exclusion criteria were: difficulty reading and speaking Swedish; mental disorder; expected survival less than one year; or participating in another study. Ethics The investigation conforms with the principles outlined in the Declaration of Helsinki.22 The Regional Research Ethics Committee at Linköping University, Linköping, Sweden, approved the study (D-nr: 104-07). All patients gave written consent after having received written and oral information about the study. They were also informed that they could withdraw from the study at any time without any explanation or consequence. Furthermore, the patients were assured that data would be treated strictly confidentially. Measures and instruments Demographic and clinical variables Demographic data, data on comorbidities and health complaints, data on sexual health (e.g. frequency of sexual activity, symptoms during intercourse), as well as data on sexual information obtained from the healthcare professionals, were all collected by self-report. Relationship assessment scale The Swedish version of the Relationship assessment scale (RAS) was used to evaluate the intimate relationship.23 The original RAS, developed by Hendrick, contains seven questions on a scale from 1 to 5 (5 being most satisfied) focusing on relationship satisfaction in healthy couples. Either the average or the total scores (7–35) can be used for comparisons.24 RAS was translated into Swedish following a back-and-forward method25 and tested for psychometric properties in a population of persons with cardiac disease.23 One item with low communality was excluded, giving a six-item RAS with a two-factor solution: ‘Relationship built on expectations and satisfaction of needs’ (factor 1) and ‘Relationship built on love and devotion’ (factor 2).23 The possible total scores thus range from 6 to 30 in the Swedish version. In the present study, the Cronbach’s alpha coefficient, including responses from all patients at time 1 (T1), was 0.75 for RAS factor 1 and 0.64 for RAS factor 2. At time 2 (T2), the corresponding coefficients were 0.76 and 0.79 for RAS factor 1 and RAS factor 2, respectively. Watts sexual function questionnaire The Swedish version of the Watts sexual function questionnaire (WSFQ) was used to evaluate sexual function. The instrument is divided into ‘sexual appetite’ and ‘sexual expectations’ with gender-neutral questions, and ‘sexual sensitiveness’ and ‘sexual ability’ with gender-specific questions.26 The male questionnaire contains items that focus on male sexual problems related to erectile and orgasmic capability (premature ejaculation and ejaculatory incompetence); whereas the female form addresses the common sexual problems of women with specific emphasis on vaginal lubrication and orgasmic capability.26 The original WSFQ contains 17 questions in which the respondents rate their answers on a 5-point Likert scale ranging from 1=never to 5=always. Items 10, 13 and 17 are reverse scored for men and items 10 and 17 for women, that is, 5=never and 1=always.27 The Swedish version has been shortened to 13 questions with the total score thus ranging from 13 to 65 with higher scores indicating a more positive sexual functioning. The Swedish version of the WSFQ has good validity and stability and acceptable internal homogeneity with Cronbach’s alpha coefficients ranging from 0.48 to 0.86 and test–retest values for all but one question exceeding 0.70.26 In the present study, the Cronbach’s alpha coefficient for the total WSFQ, including responses from all patients at T1, was 0.82 for women and 0.64 for men. At T2, the corresponding coefficients were 0.85 and 0.69 for women and men, respectively. Procedures Participants completed the questionnaires approximately 3 weeks after the MI (T1). At T1, patients were asked to report on their intimate relationship and sexual function during the year prior to the event. Identical questionnaires were again sent one year after the MI (T2), asking about the intimate relationship, sexual function and perceived quality of sexual counselling – if any – during the last year. One reminder was sent 3 weeks after each questionnaire was posted. In all, 218 patients (63 women and 155 men) met the inclusion criteria. Of those, 180 (52 women and 128 men) participated at T1, leading to a response rate of 82.6%. At T2, 52 patients did not answer the questionnaires, giving 128 responding participants (response rate based on the initial 218 patients who met the inclusion criteria: 58.7%, 36 women and 92 men). No statistically significant differences were found between patients who participated at both times as compared to those who only took part on the first occasion with regard to background characteristics, self-rated sexual health, or total RAS and WSFQ ratings at T1. Statistics Data are presented as descriptive statistics with means and standard deviations and percentages. Differences in the means (i.e. age) were analysed with the two-tailed Student’s t test. Differences in proportions were tested with the χ2 test. To compare differences in general relationship satisfaction and sexual function between two independent groups (i.e. gender) we used the Mann–Whitney U test for non-normally distributed samples. Likewise, differences in total scores in matched pairs were tested with the Wilcoxon rank sum test for non-normally distributed samples when comparing differences between TI and T2. A P value of less than 0.05 was considered to indicate a statistically significant difference. Data were analysed using SPSS 20.0 for Windows (SPSS, Inc., Chicago, IL, USA). Results A total of 128 patients, 92 men (72%), and with a mean age of 62.4±9.3 years, answered the questions on both occasions. These patients reported that they had lived with their current partner between one and 63 years with an average of 31 years. Twenty-eight per cent reported problems with tiredness, 15% had sleep disturbances and 11% suffered from anxiety; all were more common in women. The background characteristics and comparisons between genders are further presented in Table 1. Table 1. Background characteristics, N=128 Characteristics . . Valueb . . . Demographics Totala Womena Mena P value Gender (male) 92 (72) Age, years 62.4±9.3 61.3±9.5 62.8±9.2 ns Compulsory school (≤9 years) 57 (44.9) 16 (45.7) 41 (44.6) ns Years as a couple 31.3±16.1 32.9±15.4 30.7±16.4 ns Children in the household (yes) 17 (13.3) 5 (13.9) 12 (13.0) ns Sexual health Sexually active the last year (yes) 108 (85.7) 31 (88.6) 77 (84.6) ns Symptoms during intercourse (yes) 12 (9.8) 3 (9.1) 9 (10.0) Health complaints Chest pain 8 (6.5) 3 (9.4) 5 (5.4) ns Dyspnea 16 (12.8) 6 (17.6) 10 (11.0) ns Tiredness 35 (28.5) 17 (53.1) 18 (19.8) <0.001 Sleep disturbances 19 (15.1) 11 (31.4) 8 (8.8) <0.01 Dizziness 8 (6.5) 4 (12.5) 4 (4.4) ns Anxiety 13 (10.5) 7 (21.2) 6 (6.6) <0.05 Worries 12 (9.7) 5 (15.2) 7 (7.7) ns Mobility problems 13 (10.8) 3 (9.4) 10 (11.4) ns Comorbiditiesc Angina pectoris 21 (16.4) 2 (5.6) 19 (20.7) ns Hypertension 45 (35.2) 13 (36.1) 32 (34.8) ns Stroke 7 (5.5) 3 (8.3) 4 (4.3) ns Diabetes 20 (16.4) 7 (20.0) 13 (14.9) ns Asthma/COPD 17 (14.5) 7 (21.9) 10 (11.8) ns Characteristics . . Valueb . . . Demographics Totala Womena Mena P value Gender (male) 92 (72) Age, years 62.4±9.3 61.3±9.5 62.8±9.2 ns Compulsory school (≤9 years) 57 (44.9) 16 (45.7) 41 (44.6) ns Years as a couple 31.3±16.1 32.9±15.4 30.7±16.4 ns Children in the household (yes) 17 (13.3) 5 (13.9) 12 (13.0) ns Sexual health Sexually active the last year (yes) 108 (85.7) 31 (88.6) 77 (84.6) ns Symptoms during intercourse (yes) 12 (9.8) 3 (9.1) 9 (10.0) Health complaints Chest pain 8 (6.5) 3 (9.4) 5 (5.4) ns Dyspnea 16 (12.8) 6 (17.6) 10 (11.0) ns Tiredness 35 (28.5) 17 (53.1) 18 (19.8) <0.001 Sleep disturbances 19 (15.1) 11 (31.4) 8 (8.8) <0.01 Dizziness 8 (6.5) 4 (12.5) 4 (4.4) ns Anxiety 13 (10.5) 7 (21.2) 6 (6.6) <0.05 Worries 12 (9.7) 5 (15.2) 7 (7.7) ns Mobility problems 13 (10.8) 3 (9.4) 10 (11.4) ns Comorbiditiesc Angina pectoris 21 (16.4) 2 (5.6) 19 (20.7) ns Hypertension 45 (35.2) 13 (36.1) 32 (34.8) ns Stroke 7 (5.5) 3 (8.3) 4 (4.3) ns Diabetes 20 (16.4) 7 (20.0) 13 (14.9) ns Asthma/COPD 17 (14.5) 7 (21.9) 10 (11.8) ns a Some missing responses, which explain the differences in the percentages. b Data are presented as mean±SD or n (%). c Self-reported by subjects. COPD: chronic obstructive pulmonary disease. Open in new tab Table 1. Background characteristics, N=128 Characteristics . . Valueb . . . Demographics Totala Womena Mena P value Gender (male) 92 (72) Age, years 62.4±9.3 61.3±9.5 62.8±9.2 ns Compulsory school (≤9 years) 57 (44.9) 16 (45.7) 41 (44.6) ns Years as a couple 31.3±16.1 32.9±15.4 30.7±16.4 ns Children in the household (yes) 17 (13.3) 5 (13.9) 12 (13.0) ns Sexual health Sexually active the last year (yes) 108 (85.7) 31 (88.6) 77 (84.6) ns Symptoms during intercourse (yes) 12 (9.8) 3 (9.1) 9 (10.0) Health complaints Chest pain 8 (6.5) 3 (9.4) 5 (5.4) ns Dyspnea 16 (12.8) 6 (17.6) 10 (11.0) ns Tiredness 35 (28.5) 17 (53.1) 18 (19.8) <0.001 Sleep disturbances 19 (15.1) 11 (31.4) 8 (8.8) <0.01 Dizziness 8 (6.5) 4 (12.5) 4 (4.4) ns Anxiety 13 (10.5) 7 (21.2) 6 (6.6) <0.05 Worries 12 (9.7) 5 (15.2) 7 (7.7) ns Mobility problems 13 (10.8) 3 (9.4) 10 (11.4) ns Comorbiditiesc Angina pectoris 21 (16.4) 2 (5.6) 19 (20.7) ns Hypertension 45 (35.2) 13 (36.1) 32 (34.8) ns Stroke 7 (5.5) 3 (8.3) 4 (4.3) ns Diabetes 20 (16.4) 7 (20.0) 13 (14.9) ns Asthma/COPD 17 (14.5) 7 (21.9) 10 (11.8) ns Characteristics . . Valueb . . . Demographics Totala Womena Mena P value Gender (male) 92 (72) Age, years 62.4±9.3 61.3±9.5 62.8±9.2 ns Compulsory school (≤9 years) 57 (44.9) 16 (45.7) 41 (44.6) ns Years as a couple 31.3±16.1 32.9±15.4 30.7±16.4 ns Children in the household (yes) 17 (13.3) 5 (13.9) 12 (13.0) ns Sexual health Sexually active the last year (yes) 108 (85.7) 31 (88.6) 77 (84.6) ns Symptoms during intercourse (yes) 12 (9.8) 3 (9.1) 9 (10.0) Health complaints Chest pain 8 (6.5) 3 (9.4) 5 (5.4) ns Dyspnea 16 (12.8) 6 (17.6) 10 (11.0) ns Tiredness 35 (28.5) 17 (53.1) 18 (19.8) <0.001 Sleep disturbances 19 (15.1) 11 (31.4) 8 (8.8) <0.01 Dizziness 8 (6.5) 4 (12.5) 4 (4.4) ns Anxiety 13 (10.5) 7 (21.2) 6 (6.6) <0.05 Worries 12 (9.7) 5 (15.2) 7 (7.7) ns Mobility problems 13 (10.8) 3 (9.4) 10 (11.4) ns Comorbiditiesc Angina pectoris 21 (16.4) 2 (5.6) 19 (20.7) ns Hypertension 45 (35.2) 13 (36.1) 32 (34.8) ns Stroke 7 (5.5) 3 (8.3) 4 (4.3) ns Diabetes 20 (16.4) 7 (20.0) 13 (14.9) ns Asthma/COPD 17 (14.5) 7 (21.9) 10 (11.8) ns a Some missing responses, which explain the differences in the percentages. b Data are presented as mean±SD or n (%). c Self-reported by subjects. COPD: chronic obstructive pulmonary disease. Open in new tab The majority (86%) described that they had been sexually active the year before the MI event, while 80% reported that they had been sexually active the year after the event (ns). Most of the women (62%) reported having intercourse at least once a week at T1, and the corresponding frequency for the men was 67%. Both half of the women (50%) as well as the men (58%) reported having had intercourse at least once a week also the year after the MI event, which was a statistically significant reduction for the men (P<0.001) but not for the women. However, every tenth (10%) patient described troublesome symptoms during intercourse, such as erectile problems, vaginal dryness, shortness of breath, palpitations and chest pain, with no statistically significant differences between T1 and T2. About one third (36%) had received sexual counselling by healthcare professionals the year after the MI event (43% of the women and 33% of the men, ns). The majority of those patients (73%) rated the information as ‘good’ or ‘very good’. Sexual counselling was not associated with being sexually active or not during the subsequent year (36% vs. 44%, ns). General relationship satisfaction The patients scored a high general relationship satisfaction on both dimensions in the RAS; ‘Relationship built on expectations and satisfactions of needs’ (4.45±0.58 and 4.41±0.60, T1 and T2, respectively, ns), and ‘Relationship built on love and devotion’ (4.76±0.56 and 4.77±0.57, T1 and T2, respectively, ns), before (T1) as well as one year after the MI event (T2). All single item scores were also stable over time. Both at T1 and T2, the patients were most satisfied with how much they loved their partner (4.82±0.54 and 4.83±0.53, T1 and T2, respectively), while at T1 they had the lowest satisfaction with how well the partner meet their needs (4.25±0.79), and at T2 to what extent their relationship met their original expectations (4.31±0.87). No statistically significant differences between genders were found, see Table 2. Table 2. Intimate relationships measured with the Swedish version of the relationship assessment scale: patients, N=128 (women n=36, men n=92) Item content . Proportions of high satisfaction at T1, n (%)a . Mean score (SD) . P valueb . Proportions of high satisfaction at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total mean score 4.56 (0.50) ns 4.53 (0.52) ns ns Women 4.47 (0.56) 4.43 (0.62) ns Men 4.59 (0.48) 4.58 (0.48) ns Factor 1, total mean score 4.45 (0.58) ns 4.41 (0.60) ns ns Women 4.27 (0.69) 4.75 (0.58) ns Men 4.47 (0.58) 4.78 (0.57) ns How well does your partner meet your needs? 61 (48.0) 4.25 (0.79) 55 (43.0) 4.32 (0.80) ns In general, how satisfied are you with your relationship? 69 (55.3) 4.46 (0.68) 71 (55.5) 4.43 (0.73) ns To what extent has your relationship met your original expectations? 66 (51.6) 4.41 (0.72) 64 (50.0) 4.31 (0.87) ns How many problems are there in your relationship? 1 (0.8) 4.61 (0.82) 1 (0.8) 4.64 (0.77) ns Factor 2, total mean score 4.76 (0.56) ns 4.77 (0.57) ns ns Women 4.72 (0.57) 4.75 (0.58) ns Men 4.77 (0.56) 4.78 (0.57) ns How often do you wish you had not become involved in this relationship? 1 (0.8) 4.71 (0.72) 1 (0.8) 4.73 (0.70) ns How much do you love your partner? 112 (86.8) 4.82 (0.54) 112 (86.8) 4.83 (0.53) ns Item content . Proportions of high satisfaction at T1, n (%)a . Mean score (SD) . P valueb . Proportions of high satisfaction at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total mean score 4.56 (0.50) ns 4.53 (0.52) ns ns Women 4.47 (0.56) 4.43 (0.62) ns Men 4.59 (0.48) 4.58 (0.48) ns Factor 1, total mean score 4.45 (0.58) ns 4.41 (0.60) ns ns Women 4.27 (0.69) 4.75 (0.58) ns Men 4.47 (0.58) 4.78 (0.57) ns How well does your partner meet your needs? 61 (48.0) 4.25 (0.79) 55 (43.0) 4.32 (0.80) ns In general, how satisfied are you with your relationship? 69 (55.3) 4.46 (0.68) 71 (55.5) 4.43 (0.73) ns To what extent has your relationship met your original expectations? 66 (51.6) 4.41 (0.72) 64 (50.0) 4.31 (0.87) ns How many problems are there in your relationship? 1 (0.8) 4.61 (0.82) 1 (0.8) 4.64 (0.77) ns Factor 2, total mean score 4.76 (0.56) ns 4.77 (0.57) ns ns Women 4.72 (0.57) 4.75 (0.58) ns Men 4.77 (0.56) 4.78 (0.57) ns How often do you wish you had not become involved in this relationship? 1 (0.8) 4.71 (0.72) 1 (0.8) 4.73 (0.70) ns How much do you love your partner? 112 (86.8) 4.82 (0.54) 112 (86.8) 4.83 (0.53) ns a Some missing responses, which explain the differences in the percentages. b Mean comparison between gender at T1. c Mean comparison between gender at T2. d Mean comparison between T1 and T2 and within gender (pair) at T1 and T2. Scores range from 1 (low satisfaction) to 5 (high satisfaction), items 4 and 5 are reverse scored. T1: time 1; T2: time 2. Open in new tab Table 2. Intimate relationships measured with the Swedish version of the relationship assessment scale: patients, N=128 (women n=36, men n=92) Item content . Proportions of high satisfaction at T1, n (%)a . Mean score (SD) . P valueb . Proportions of high satisfaction at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total mean score 4.56 (0.50) ns 4.53 (0.52) ns ns Women 4.47 (0.56) 4.43 (0.62) ns Men 4.59 (0.48) 4.58 (0.48) ns Factor 1, total mean score 4.45 (0.58) ns 4.41 (0.60) ns ns Women 4.27 (0.69) 4.75 (0.58) ns Men 4.47 (0.58) 4.78 (0.57) ns How well does your partner meet your needs? 61 (48.0) 4.25 (0.79) 55 (43.0) 4.32 (0.80) ns In general, how satisfied are you with your relationship? 69 (55.3) 4.46 (0.68) 71 (55.5) 4.43 (0.73) ns To what extent has your relationship met your original expectations? 66 (51.6) 4.41 (0.72) 64 (50.0) 4.31 (0.87) ns How many problems are there in your relationship? 1 (0.8) 4.61 (0.82) 1 (0.8) 4.64 (0.77) ns Factor 2, total mean score 4.76 (0.56) ns 4.77 (0.57) ns ns Women 4.72 (0.57) 4.75 (0.58) ns Men 4.77 (0.56) 4.78 (0.57) ns How often do you wish you had not become involved in this relationship? 1 (0.8) 4.71 (0.72) 1 (0.8) 4.73 (0.70) ns How much do you love your partner? 112 (86.8) 4.82 (0.54) 112 (86.8) 4.83 (0.53) ns Item content . Proportions of high satisfaction at T1, n (%)a . Mean score (SD) . P valueb . Proportions of high satisfaction at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total mean score 4.56 (0.50) ns 4.53 (0.52) ns ns Women 4.47 (0.56) 4.43 (0.62) ns Men 4.59 (0.48) 4.58 (0.48) ns Factor 1, total mean score 4.45 (0.58) ns 4.41 (0.60) ns ns Women 4.27 (0.69) 4.75 (0.58) ns Men 4.47 (0.58) 4.78 (0.57) ns How well does your partner meet your needs? 61 (48.0) 4.25 (0.79) 55 (43.0) 4.32 (0.80) ns In general, how satisfied are you with your relationship? 69 (55.3) 4.46 (0.68) 71 (55.5) 4.43 (0.73) ns To what extent has your relationship met your original expectations? 66 (51.6) 4.41 (0.72) 64 (50.0) 4.31 (0.87) ns How many problems are there in your relationship? 1 (0.8) 4.61 (0.82) 1 (0.8) 4.64 (0.77) ns Factor 2, total mean score 4.76 (0.56) ns 4.77 (0.57) ns ns Women 4.72 (0.57) 4.75 (0.58) ns Men 4.77 (0.56) 4.78 (0.57) ns How often do you wish you had not become involved in this relationship? 1 (0.8) 4.71 (0.72) 1 (0.8) 4.73 (0.70) ns How much do you love your partner? 112 (86.8) 4.82 (0.54) 112 (86.8) 4.83 (0.53) ns a Some missing responses, which explain the differences in the percentages. b Mean comparison between gender at T1. c Mean comparison between gender at T2. d Mean comparison between T1 and T2 and within gender (pair) at T1 and T2. Scores range from 1 (low satisfaction) to 5 (high satisfaction), items 4 and 5 are reverse scored. T1: time 1; T2: time 2. Open in new tab Sexual function The year before the MI event, the total score for the WSFQ was 45.92±6.55 and 48.59±4.96 (out of 65 possible scores) for women and men, respectively (P<0.05). The year after the MI event, the women reported a mean score of 45.08±7.25, while the men had a mean score of 47.10±5.16 (P<0.01). This implies that the women reported an unchanged sexual function the year after the MI event, while the men had decreased their sexual function (P<0.05). The only individual item score that changed between T1 and T2 for the female patients was that they less frequently reported ‘enjoyed sexual activity’ the year after the MI event (4.03±0.71 vs. 3.58±1.18, P<0.05). The male patients regarded ‘having sex’ as being a less important part of their life the year after the MI event (3.87±0.97 vs. 3.55±0.97, P<0.001). As for the women, they also ‘enjoyed sexual activity’ less frequently (4.45±0.88 vs. 4.16±0.91, P<0.001). Finally, the men were less satisfied ‘with the frequency of sexual activity’ (3.79±1.03 vs. 3.53±1.07, P<0.05), and felt that they more often ‘ejaculated too soon’ (3.52±0.77 vs. 3.69±0.85, P<0.05) during the past year compared to before the MI event, see Table 3. Table 3. Sexual function measured with the Swedish version of the Watts sexual function questionnaire: patients N=128 (women n=36, men n=92) Item . Proportions of scoring ‘always’ at T1, n (%)a . Mean score (SD) . P valueb . Proportions of scoring ‘always’ at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total score 0.05 0.01 Women 45.92 (6.56) 45.08 (7.25) ns Men 48.59 (4.96) 47.10 (5.16) 0.05 Sexual appetite (gender neutral) (1, 2, 5, 15, 16) To what extent is ‘having sex’ an important part of your life? ns ns Women 5 (16.7) 3.50 (0.90) 2 (6.5) 3.35 (0.76) ns Men 25 (28.1) 3.87 (0.97) 15 (17.0) 3.55 (0.97) 0.001 How frequently did you enjoy sexual activity? ns 0.05 Women 7 (22.6) 4.03 (0.71) 6 (19.4) 3.58 (1.18) 0.05 Men 53 (59.6) 4.45 (0.88) 36 (40.9) 4.16 (0.91) 0.001 How often did you have a desire for sex with partner? ns 0.05 Women 3 (9.7) 3.35 (0.66) 0 (0.0) 3.13 (0.62) ns Men 11 (12.5) 3.56 (0.91) 7 (8.0) 3.46 (0.82) ns To what extent did you feel satisfied after sexual activity? ns 0.01 Women 10 (32.3) 4.10 (0.75) 7 (23.3) 3.93 (0.83) ns Men 38 (42.7) 4.34 (0.74) 33 (33.9) 4.18 (0.88) ns How often were you satisfied with the frequency of sexual activity? 0.05 ns Women 7 (23.3) 3.87 (0.90) 6 (21.4) 3.68 (0.98) ns Men 21 (23.6) 3.79 (1.03) 12 (14.0) 3.53 (1.07) 0.05 Sexual expectations (gender neutral) (4, 6, 17) How frequently did you have daydreams or a fantasy about sex? ns 0.05 Women 0 (0.0) 2.23 (0.73) 0 (0.0) 2.16 (0.85) ns Men 3 (3.4) 2.64 (0.86) 2 (2.3) 2.67 (0.92) ns To what extent did you want sex more than your partner? 0.01 0.001 Women 1 (3.2) 2.19 (0.87) 0 (0.0) 2.13 (0.71) ns Men 6 (6.8) 2.95 (1.06) 4 (4.5) 2.94 (0.95) ns How frequently did you feel tense or nervous after a sexual experience? e 0.001 ns Women 23 (74.2) 4.68 (0.60) 20 (66.7) 4.47 (0.94) ns Men 54 (60.7) 4.51 (0.74) 56 (64.4) 4.48 (0.86) ns Sexual sensitiveness (10, 13, 14) How often did you feel pain or discomfort during sexual intercourse? e 0.05 0.001 Women 18 (58.1) 4.45 (0.72) 17 (56.7) 4.33 (0.84) ns How frequently did you lose a hard erection before ‘coming’ (ejaculating)?e Men 19 (21.6) 2.71 (0.84) 9 (10.5) 3.59 (0.83) ns How often were you able to reach a climax (come)? Women 5 (16.1) 3.77 (0.80) 0.01 5 (16.7) 3.67 (0.99) 0.001 ns How frequently did you have other problems in ‘coming’ (ejaculating)? Men 33 (37.1) 4.16 (0.86) 26 (29.9) 3.97 (0.88) ns To what extent was it important for you to reach a climax (come)? ns 0.01 Women 2 (6.7) 3.30 (1.09) 3 (10.3) 3.38 (0.94) ns How often did you ejaculate through a flaccid penis? Men 1 (1.1) 4.56 (0.71) 0 (0.0) 4.57 (0.72) ns Sexual ability (7, 12) During your last sexual experience, to what extent were you aware of wetness in your vagina as you became sexually excited? 0.01 0.01 Women 11 (36.7) 3.77 (1.28) 7 (22.6) 3.52 (1.15) ns How often did you wake up with erection in the morning? Men 2 (2.2) 2.71 (0.84) 2 (2.3) 2.70 (0.83) ns As sexual excitement became more intense, how often were you aware of throbbing sensations in your vagina? 0.001 ns Women 2 (6.5) 3.16 (1.00) 3 (10.3) 3.21 (1.08) ns How often did you feel that you ‘came’ (ejaculated) too soon? Men 1 (1.1) 3.52 (0.77) 0 (0.0) 3.69 (0.85) 0.05 Item . Proportions of scoring ‘always’ at T1, n (%)a . Mean score (SD) . P valueb . Proportions of scoring ‘always’ at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total score 0.05 0.01 Women 45.92 (6.56) 45.08 (7.25) ns Men 48.59 (4.96) 47.10 (5.16) 0.05 Sexual appetite (gender neutral) (1, 2, 5, 15, 16) To what extent is ‘having sex’ an important part of your life? ns ns Women 5 (16.7) 3.50 (0.90) 2 (6.5) 3.35 (0.76) ns Men 25 (28.1) 3.87 (0.97) 15 (17.0) 3.55 (0.97) 0.001 How frequently did you enjoy sexual activity? ns 0.05 Women 7 (22.6) 4.03 (0.71) 6 (19.4) 3.58 (1.18) 0.05 Men 53 (59.6) 4.45 (0.88) 36 (40.9) 4.16 (0.91) 0.001 How often did you have a desire for sex with partner? ns 0.05 Women 3 (9.7) 3.35 (0.66) 0 (0.0) 3.13 (0.62) ns Men 11 (12.5) 3.56 (0.91) 7 (8.0) 3.46 (0.82) ns To what extent did you feel satisfied after sexual activity? ns 0.01 Women 10 (32.3) 4.10 (0.75) 7 (23.3) 3.93 (0.83) ns Men 38 (42.7) 4.34 (0.74) 33 (33.9) 4.18 (0.88) ns How often were you satisfied with the frequency of sexual activity? 0.05 ns Women 7 (23.3) 3.87 (0.90) 6 (21.4) 3.68 (0.98) ns Men 21 (23.6) 3.79 (1.03) 12 (14.0) 3.53 (1.07) 0.05 Sexual expectations (gender neutral) (4, 6, 17) How frequently did you have daydreams or a fantasy about sex? ns 0.05 Women 0 (0.0) 2.23 (0.73) 0 (0.0) 2.16 (0.85) ns Men 3 (3.4) 2.64 (0.86) 2 (2.3) 2.67 (0.92) ns To what extent did you want sex more than your partner? 0.01 0.001 Women 1 (3.2) 2.19 (0.87) 0 (0.0) 2.13 (0.71) ns Men 6 (6.8) 2.95 (1.06) 4 (4.5) 2.94 (0.95) ns How frequently did you feel tense or nervous after a sexual experience? e 0.001 ns Women 23 (74.2) 4.68 (0.60) 20 (66.7) 4.47 (0.94) ns Men 54 (60.7) 4.51 (0.74) 56 (64.4) 4.48 (0.86) ns Sexual sensitiveness (10, 13, 14) How often did you feel pain or discomfort during sexual intercourse? e 0.05 0.001 Women 18 (58.1) 4.45 (0.72) 17 (56.7) 4.33 (0.84) ns How frequently did you lose a hard erection before ‘coming’ (ejaculating)?e Men 19 (21.6) 2.71 (0.84) 9 (10.5) 3.59 (0.83) ns How often were you able to reach a climax (come)? Women 5 (16.1) 3.77 (0.80) 0.01 5 (16.7) 3.67 (0.99) 0.001 ns How frequently did you have other problems in ‘coming’ (ejaculating)? Men 33 (37.1) 4.16 (0.86) 26 (29.9) 3.97 (0.88) ns To what extent was it important for you to reach a climax (come)? ns 0.01 Women 2 (6.7) 3.30 (1.09) 3 (10.3) 3.38 (0.94) ns How often did you ejaculate through a flaccid penis? Men 1 (1.1) 4.56 (0.71) 0 (0.0) 4.57 (0.72) ns Sexual ability (7, 12) During your last sexual experience, to what extent were you aware of wetness in your vagina as you became sexually excited? 0.01 0.01 Women 11 (36.7) 3.77 (1.28) 7 (22.6) 3.52 (1.15) ns How often did you wake up with erection in the morning? Men 2 (2.2) 2.71 (0.84) 2 (2.3) 2.70 (0.83) ns As sexual excitement became more intense, how often were you aware of throbbing sensations in your vagina? 0.001 ns Women 2 (6.5) 3.16 (1.00) 3 (10.3) 3.21 (1.08) ns How often did you feel that you ‘came’ (ejaculated) too soon? Men 1 (1.1) 3.52 (0.77) 0 (0.0) 3.69 (0.85) 0.05 a Some missing responses, which explain the differences in the percentages. b Mean comparison between gender at T1. c Mean comparison between gender at T2. d Mean comparison within gender (pair) at T1 and T2. e Items 10, 13 and 17 are reverse scored for men and items 10 and 17 for women, respectively, i.e. proportions of scoring ‘never’. T1: time 1; T2: time 2. Open in new tab Table 3. Sexual function measured with the Swedish version of the Watts sexual function questionnaire: patients N=128 (women n=36, men n=92) Item . Proportions of scoring ‘always’ at T1, n (%)a . Mean score (SD) . P valueb . Proportions of scoring ‘always’ at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total score 0.05 0.01 Women 45.92 (6.56) 45.08 (7.25) ns Men 48.59 (4.96) 47.10 (5.16) 0.05 Sexual appetite (gender neutral) (1, 2, 5, 15, 16) To what extent is ‘having sex’ an important part of your life? ns ns Women 5 (16.7) 3.50 (0.90) 2 (6.5) 3.35 (0.76) ns Men 25 (28.1) 3.87 (0.97) 15 (17.0) 3.55 (0.97) 0.001 How frequently did you enjoy sexual activity? ns 0.05 Women 7 (22.6) 4.03 (0.71) 6 (19.4) 3.58 (1.18) 0.05 Men 53 (59.6) 4.45 (0.88) 36 (40.9) 4.16 (0.91) 0.001 How often did you have a desire for sex with partner? ns 0.05 Women 3 (9.7) 3.35 (0.66) 0 (0.0) 3.13 (0.62) ns Men 11 (12.5) 3.56 (0.91) 7 (8.0) 3.46 (0.82) ns To what extent did you feel satisfied after sexual activity? ns 0.01 Women 10 (32.3) 4.10 (0.75) 7 (23.3) 3.93 (0.83) ns Men 38 (42.7) 4.34 (0.74) 33 (33.9) 4.18 (0.88) ns How often were you satisfied with the frequency of sexual activity? 0.05 ns Women 7 (23.3) 3.87 (0.90) 6 (21.4) 3.68 (0.98) ns Men 21 (23.6) 3.79 (1.03) 12 (14.0) 3.53 (1.07) 0.05 Sexual expectations (gender neutral) (4, 6, 17) How frequently did you have daydreams or a fantasy about sex? ns 0.05 Women 0 (0.0) 2.23 (0.73) 0 (0.0) 2.16 (0.85) ns Men 3 (3.4) 2.64 (0.86) 2 (2.3) 2.67 (0.92) ns To what extent did you want sex more than your partner? 0.01 0.001 Women 1 (3.2) 2.19 (0.87) 0 (0.0) 2.13 (0.71) ns Men 6 (6.8) 2.95 (1.06) 4 (4.5) 2.94 (0.95) ns How frequently did you feel tense or nervous after a sexual experience? e 0.001 ns Women 23 (74.2) 4.68 (0.60) 20 (66.7) 4.47 (0.94) ns Men 54 (60.7) 4.51 (0.74) 56 (64.4) 4.48 (0.86) ns Sexual sensitiveness (10, 13, 14) How often did you feel pain or discomfort during sexual intercourse? e 0.05 0.001 Women 18 (58.1) 4.45 (0.72) 17 (56.7) 4.33 (0.84) ns How frequently did you lose a hard erection before ‘coming’ (ejaculating)?e Men 19 (21.6) 2.71 (0.84) 9 (10.5) 3.59 (0.83) ns How often were you able to reach a climax (come)? Women 5 (16.1) 3.77 (0.80) 0.01 5 (16.7) 3.67 (0.99) 0.001 ns How frequently did you have other problems in ‘coming’ (ejaculating)? Men 33 (37.1) 4.16 (0.86) 26 (29.9) 3.97 (0.88) ns To what extent was it important for you to reach a climax (come)? ns 0.01 Women 2 (6.7) 3.30 (1.09) 3 (10.3) 3.38 (0.94) ns How often did you ejaculate through a flaccid penis? Men 1 (1.1) 4.56 (0.71) 0 (0.0) 4.57 (0.72) ns Sexual ability (7, 12) During your last sexual experience, to what extent were you aware of wetness in your vagina as you became sexually excited? 0.01 0.01 Women 11 (36.7) 3.77 (1.28) 7 (22.6) 3.52 (1.15) ns How often did you wake up with erection in the morning? Men 2 (2.2) 2.71 (0.84) 2 (2.3) 2.70 (0.83) ns As sexual excitement became more intense, how often were you aware of throbbing sensations in your vagina? 0.001 ns Women 2 (6.5) 3.16 (1.00) 3 (10.3) 3.21 (1.08) ns How often did you feel that you ‘came’ (ejaculated) too soon? Men 1 (1.1) 3.52 (0.77) 0 (0.0) 3.69 (0.85) 0.05 Item . Proportions of scoring ‘always’ at T1, n (%)a . Mean score (SD) . P valueb . Proportions of scoring ‘always’ at T2, n (%)a . Mean score (SD) . P valuec . P valued . Total score 0.05 0.01 Women 45.92 (6.56) 45.08 (7.25) ns Men 48.59 (4.96) 47.10 (5.16) 0.05 Sexual appetite (gender neutral) (1, 2, 5, 15, 16) To what extent is ‘having sex’ an important part of your life? ns ns Women 5 (16.7) 3.50 (0.90) 2 (6.5) 3.35 (0.76) ns Men 25 (28.1) 3.87 (0.97) 15 (17.0) 3.55 (0.97) 0.001 How frequently did you enjoy sexual activity? ns 0.05 Women 7 (22.6) 4.03 (0.71) 6 (19.4) 3.58 (1.18) 0.05 Men 53 (59.6) 4.45 (0.88) 36 (40.9) 4.16 (0.91) 0.001 How often did you have a desire for sex with partner? ns 0.05 Women 3 (9.7) 3.35 (0.66) 0 (0.0) 3.13 (0.62) ns Men 11 (12.5) 3.56 (0.91) 7 (8.0) 3.46 (0.82) ns To what extent did you feel satisfied after sexual activity? ns 0.01 Women 10 (32.3) 4.10 (0.75) 7 (23.3) 3.93 (0.83) ns Men 38 (42.7) 4.34 (0.74) 33 (33.9) 4.18 (0.88) ns How often were you satisfied with the frequency of sexual activity? 0.05 ns Women 7 (23.3) 3.87 (0.90) 6 (21.4) 3.68 (0.98) ns Men 21 (23.6) 3.79 (1.03) 12 (14.0) 3.53 (1.07) 0.05 Sexual expectations (gender neutral) (4, 6, 17) How frequently did you have daydreams or a fantasy about sex? ns 0.05 Women 0 (0.0) 2.23 (0.73) 0 (0.0) 2.16 (0.85) ns Men 3 (3.4) 2.64 (0.86) 2 (2.3) 2.67 (0.92) ns To what extent did you want sex more than your partner? 0.01 0.001 Women 1 (3.2) 2.19 (0.87) 0 (0.0) 2.13 (0.71) ns Men 6 (6.8) 2.95 (1.06) 4 (4.5) 2.94 (0.95) ns How frequently did you feel tense or nervous after a sexual experience? e 0.001 ns Women 23 (74.2) 4.68 (0.60) 20 (66.7) 4.47 (0.94) ns Men 54 (60.7) 4.51 (0.74) 56 (64.4) 4.48 (0.86) ns Sexual sensitiveness (10, 13, 14) How often did you feel pain or discomfort during sexual intercourse? e 0.05 0.001 Women 18 (58.1) 4.45 (0.72) 17 (56.7) 4.33 (0.84) ns How frequently did you lose a hard erection before ‘coming’ (ejaculating)?e Men 19 (21.6) 2.71 (0.84) 9 (10.5) 3.59 (0.83) ns How often were you able to reach a climax (come)? Women 5 (16.1) 3.77 (0.80) 0.01 5 (16.7) 3.67 (0.99) 0.001 ns How frequently did you have other problems in ‘coming’ (ejaculating)? Men 33 (37.1) 4.16 (0.86) 26 (29.9) 3.97 (0.88) ns To what extent was it important for you to reach a climax (come)? ns 0.01 Women 2 (6.7) 3.30 (1.09) 3 (10.3) 3.38 (0.94) ns How often did you ejaculate through a flaccid penis? Men 1 (1.1) 4.56 (0.71) 0 (0.0) 4.57 (0.72) ns Sexual ability (7, 12) During your last sexual experience, to what extent were you aware of wetness in your vagina as you became sexually excited? 0.01 0.01 Women 11 (36.7) 3.77 (1.28) 7 (22.6) 3.52 (1.15) ns How often did you wake up with erection in the morning? Men 2 (2.2) 2.71 (0.84) 2 (2.3) 2.70 (0.83) ns As sexual excitement became more intense, how often were you aware of throbbing sensations in your vagina? 0.001 ns Women 2 (6.5) 3.16 (1.00) 3 (10.3) 3.21 (1.08) ns How often did you feel that you ‘came’ (ejaculated) too soon? Men 1 (1.1) 3.52 (0.77) 0 (0.0) 3.69 (0.85) 0.05 a Some missing responses, which explain the differences in the percentages. b Mean comparison between gender at T1. c Mean comparison between gender at T2. d Mean comparison within gender (pair) at T1 and T2. e Items 10, 13 and 17 are reverse scored for men and items 10 and 17 for women, respectively, i.e. proportions of scoring ‘never’. T1: time 1; T2: time 2. Open in new tab Both at T1 and T2, the male patients reported higher scores compared to their female counterparts when it comes to ‘wanting to have sex more than their partner’ (T1: 2.95±1.06 vs. 2.19±0.87, respectively, P<0.01; T2: 2.94±0.95 vs. 2.13±0.71, P<0.001). The men were also less pleased with ‘how often they were satisfied with the frequency of sexual activity’ compared to the women (3.79±1.03 vs. 3.87±0.90, P<0.05) at T1, but one year after the MI event no statistically significant differences remained (3.53±1.07 vs. 3.68±0.98, ns). The women reported that they more frequently ‘felt tense or nervous after a sexual experience’ (4.68±0.60 vs. 4.51±0.74, P<0.001) at T1, but at the follow-up there was no statistically significant difference in scoring on this item between genders (4.47±0.94 vs.4.48±0.86, ns). The year after the MI event, the men reported that they ‘more frequently enjoyed sexual activity’ compared to their female counterparts (4.16±0.91 vs. 3.58±1.18, P<0.05), they also more often ‘had a desire for sex with their partner’ (3.46±0.82 vs. 3.13±0.62, P<0.05), and ‘felt satisfied after sexual activity’ (4.18±0.88 vs. 3.93±0.83, P<0.01), see Table 3. At both T1 and T2, the lowest individual scoring for the women was reported on the item ‘to what extent did you want sex more than your partner’ (2.19±0.87 and 2.13±0.71, T1 and T2, respectively, ns), while the men scored lowest on the item ‘how frequently did you have daydreams or a fantasy about sex’ (2.64±0.86 and 2.67±0.92, T1 and T2, respectively, ns). The highest scoring was by the women given the reversed item ‘how frequently did you feel tense or nervous after a sexual experience’ with a mean score of 4.68±0.60 and 4.47±0.94, for T1 and T2, respectively (ns). The men scored highest on the item ‘how often did you ejaculate through a flaccid penis’ on both occasions (4.56±0.71 and 4.57±0.72, T1 and T2, respectively, ns), see Table 3. Discussion The results of our study corroborate and extend previous findings about how intimate relationships, including sexuality, constitute an important and meaningful context in partnered patients’ wellbeing following a first MI. We found that patients’ ratings of their general intimate relationship satisfaction were high, both before, and the year after the MI event (Table 2). This is congruent with earlier published results from our research group seen from the perspective of the partners.21 In contrast, previous studies using in-depth interviews have found negative influences on the marital and intimate relationship following an MI.28,29 A systematic literature review on partner relationship found – even though most couples experienced great distress following being afflicted with an MI – that they reported that the disease had brought them closer together.30 This is in line with our result concerning highly scored satisfaction, stable over time, among the patients, concerning terms of expectations and satisfaction of needs, and love and devotion in their intimate relationship (Table 2). Our patients tended to decrease their sexual activity the year following the MI, with a decrease of 6%; but the difference was not statistically significant. Nevertheless, the men reported that having sex was a less important part of their life, and they were less satisfied with the frequency of sexual activity the year following the MI. The men also described a decreased sexual function in general, and felt that they had more often ejaculated prematurely during the past year compared to before the MI event (Table 3). This is of the utmost importance because a recent meta-analysis showed that the presence of erectile dysfunction in MI patients increases the risk of future cardiovascular events, MI, cerebrovascular events, as well as all-cause mortality.31 A previous study has found that rates of sexual dysfunction also among women with cardiovascular disease are twice as high as those in the general population.32 Our findings indicate that the women had a lower sexual function both the year before the MI, as well as the subsequent year, compared to the men. However, the women’s sexual function was stable over time (Table 3). One explanation for this could be the higher prevalence of tiredness, sleep disturbances and general anxiety described in the women in comparison with the men, possibly affecting the women’s sexual desire (Table 1). However, both men and women reported that they enjoyed sexual activity less frequently (Table 3). Also, a recent integrative literature review showed that many patients present with sexual dysfunction after an MI event, often as an adverse effect of medication, or they become afraid of resuming sexual life, fearing that some adverse events such as chest pain, a recurrent MI or sudden death will occur.33 Men and women are often different in their arousal patterns. Typically, women will focus on feeling ‘desired’ or ‘attractive’ to their man, while typically men will focus on feeling ‘invited’ or ‘welcomed’ to engage in sex.34 Sexual confidence, then, is more about function for men while women’s confidence may involve trust, security and caring. This difference in sexual function and arousal patterns between men and women points out the importance of taking into consideration gender aspects when counselling patients after an MI event. Furthermore, others have described that men, to a greater extent than women, want and report receiving more information about sexual activity.35 The importance of timely and tailored information, as well as appropriate referrals for sexual counselling, is vital. Still, sexuality in relation to heart disease is not routinely discussed in the CR setting,16,19,36 leaving the patients with limited knowledge about sexual health and sexual activity.37 This lack of information is concurrent with our findings, with just one third of the patients reporting that the healthcare professionals had addressed sexuality as a topic during the CR programme. It is common for healthcare professionals to feel uncomfortable in initiating a dialogue about sexuality related to lack of knowledge, discomfort in addressing the subject and a feeling of invading the privacy of patients, in addition to personal beliefs, attitudes and behaviour.38 However, as sexual function is an important component in quality of life and activities of daily living, healthcare professionals should receive training in addressing sexuality in the treatment of post-MI patients.1,14 General suggestions to the patient may include being well rested at the time of sexual activity, avoiding unfamiliar surroundings and partners in order to minimize stress during sexual activity, avoiding heavy meals or alcohol before sexual activity, and using a position that does not restrict respiration.39–41 Hartmann and Burkart42 maintained that a short patient questionnaire is an excellent aid for patients and healthcare professionals for initiating discussions about sexuality, and it has been suggested26 that the WSFQ used in our study can form the basis for such a communication between patients with heart diseases and healthcare professionals. A great advantage of this questionnaire is that it has both gender and non-gender-specific questions. The strengths of the present study are a representative sample nationally and a longitudinal design examining ratings of sexual functioning and intimate relationships both before and one year post-MI. This study also has some limitations. It should be noted that the patients answered the first questionnaire a few weeks after their MI, and were at that point asked retrospectively to assess their experiences one year prior to the MI event, which may reflect recall bias. The newly experienced MI event may have affected the assessment of the intimate relationship at T1, and this potential bias could explain the stable relationship ratings over time in our study. However, it is not surprising that the majority of patients rated their intimate relationship as very good, as most of them had lived with their current partner for many years. The findings presented are based on those who agreed to participate in this study and therefore may reflect attribution bias. This study is also limited by the rather low sample size and the attrition rates over a one-year period (from T1 to T2), with 71% of the patients who participated at T1 also participating at T2. However, no statistically significant differences were found between patients who participated at both times as compared to those who only took part on the first occasion with regard to background characteristics, self-rated sexual health, or total RAS and WSFQ ratings at T1. Finally, we did not ask questions about specific content in the sexual counselling with healthcare professionals after the MI – or who had initiated such a conversation – just if a dialogue had occurred and how the patients rated its content. Conclusions Partnered first-time MI patients continue to be sexually active the subsequent year, and are highly satisfied with their intimate relationship. While the MI event itself seems to have a more negative impact on men’s sexual functioning than women’s, the women still rate their sexual function lower in comparison. Sexuality is not routinely discussed in the CR setting, suggesting that more attention to this subject among healthcare professionals is needed. Acknowledgement The authors would like to thank the participants for taking part in the study, and the SAMMI study group for fruitful collaboration during the project. Conflict of interest statement The authors have no conflicts of interest to declare. Funding The study was funded by the Strategic Research Programme in Health Care Sciences (SFO-V), ‘Bridging Research and Practice for Better Health’, Karolinska Institutet Stockholm and Umeå University, Sweden. Implications for practice Troublesome symptoms during intercourse are common and should be addressed by the healthcare professionals. 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Journal

European Journal of Cardiovascular Nursing – Oxford University Press

Published: Dec 1, 2015

Keywords: myocardial infarction; sexual function; watt; assessment scales; sex behavior; gender

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