Introduction
Sexual activity is an important component of quality of life for patients after myocardial infarction (MI). However, resuming sexual intercourse often raises concerns among both patients and healthcare providers. Available data indicate that after an uncomplicated MI, sexual activity can usually be resumed after approximately 1–2 weeks, provided there are no cardiac symptoms during mild to moderate physical activity. According to the Princeton III Conference recommendations, resuming sexual intercourse may be considered approximately 3 weeks after the event, especially in patients with a negative exercise test without evidence of myocardial ischemia. The exertion associated with sexual activity corresponds to a workload of approximately 3–5 metabolic equivalents of exercise (METs). Patients able to achieve this level of exercise without symptoms are considered at very low risk of cardiovascular events. Current guidelines emphasize the need for individualized decisions regarding resuming sexual activity, taking into account clinical stability, exercise capacity, and the course of cardiac treatment. Cardiac rehabilitation and structured counseling for patients play an important role in this respect [1, 2].
Phosphodiesterase type 5 inhibitors (PDE5i) are considered safe in most patients with stable coronary artery disease and do not appear to increase the risk of cardiovascular events. However, their concomitant use with nitrates remains contraindicated due to the risk of severe hypotension [3, 4]. Erectile dysfunction (ED) is common in patients with coronary artery disease, after acute coronary syndrome, or after percutaneous coronary intervention (PCI), with a prevalence estimated at approximately 64–90%, depending on the population studied. It is increasingly recognized as an early manifestation of systemic endothelial dysfunction and atherosclerosis. Impaired nitric oxide bioavailability and endothelial dysfunction play a central role in both coronary artery disease and ED, linking these conditions at the pathophysiological level. According to the “artery size hypothesis”, smaller penile arteries may become symptomatic earlier than coronary vessels, making ED a potential early clinical marker of subclinical atherosclerosis. Moreover, new ED after a first myocardial infarction often appears in the first months after the event and is strongly associated with age and the presence of comorbidities, especially diabetes [5–7].
Observational study data indicate a persistent gap in sexual counseling following myocardial infarction or PCI, even though patients often expect clear information regarding the safe return to sexual intercourse [8]. Pharmacotherapy administered after myocardial infarction or PCI may affect erectile function, and in the case of ED in cardiac patients, treatment modifications may be possible while maintaining safety [9, 10]. Despite the growing number of publications on sexual function in patients with coronary artery disease, relatively few studies have simultaneously assessed the incidence of ED, the level of anxiety associated with sexual activity, and the scope of sexual health counseling in the early post-myocardial infarction period, especially in the PCI patient population.
Aim
The aim of this study was to assess the incidence of ED in men 4–12 weeks after myocardial infarction treated with PCI and to analyze its association with selected clinical characteristics, discharge pharmacotherapy, and the level of counseling regarding return to sexual activity and the safety of PDE5 inhibitors.
Material and methods
Study design and population
A single-center observational study was conducted with survey assessments conducted 4–12 weeks after hospital discharge. Patient recruitment was conducted from January 2024 to December 2025 in the clinical department of cardiology of a hospital located in the Masovian Voivodeship, Poland. Consecutive men aged ≥ 18 years after myocardial infarction (STEMI or NSTEMI) treated with PCI were enrolled. Patients were excluded if they were unable to provide informed consent, were unable to reliably complete the survey, or had an unstable clinical condition during the follow-up period that prevented assessment of sexual function (e.g., recurrent myocardial infarction or significant decompensation of heart failure). Due to the exploratory nature of the study, no formal sample size calculation was performed, and all consecutive patients who met the inclusion criteria during the recruitment period were included in the analysis.
Data collection and definitions
Clinical data were obtained from the medical records of the index hospitalization and the discharge summary. Demographic and clinical information was collected, including age, selected cardiovascular risk factors, type of myocardial infarction, baseline left ventricular ejection fraction (LVEF) assessed by echocardiography during the index hospitalization, comorbidities, and discharge medication. Patients completed the survey independently during their follow-up visit, ensuring privacy and confidentiality. The questionnaire was anonymous and did not contain any personally identifiable information. Patients were provided with a private environment to limit the influence of social factors and enhance the reliability of their responses. Erectile function was assessed using the short version of the International Index of Erectile Function (IIEF-5). Scores range from 5 to 25, with lower scores indicating greater severity of ED; ED was defined as a score of ≤ 21. The survey also assessed the level of anxiety related to sexual activity (ordinal scale 1–5), resumption of sexual intercourse since discharge from the hospital (yes/no), and elements of discharge counseling, including providing information on safe return to sexual activity and discussing contraindications to the concomitant use of PDE5 inhibitors and nitrates (yes/no/I don’t remember).
Statistical analysis
Continuous variables were presented as mean and standard deviation (SD), and qualitative variables were presented as numbers and percentages. Normality of distribution was assessed using the Shapiro–Wilk test. Student’s t-test for independent samples was used to compare continuous variables between groups, while qualitative variables were compared using the χ2 test or Fisher’s exact test. The association between the occurrence of ED (defined as an IIEF-5 score ≤ 21) and selected clinical variables was assessed in univariate analyses. Variables that were statistically significant in univariate analysis were then included in multivariate analysis using logistic regression to identify independent factors associated with the occurrence of ED. The level of statistical significance was set at p < 0.05. Statistical analyses were performed in R (version 4.3.3; R Core Team, 2024). Analyses were performed for the complete data set, without missing values in the analyzed variables.
Results
The study included 200 consecutive men presenting for a follow-up visit 4–12 weeks after myocardial infarction treated with PCI. Clinical characteristics of the study population are presented in Table I. Erectile dysfunction (ED; IIEF-5 ≤ 21) was observed in 118 (59.0%) patients. Patients with ED were significantly older than those without ED (66 ±9 vs. 58 ±10 years; p < 0.001) and ED was more common in patients with diabetes (40.7% vs. 24.4%; p = 0.01). However, no significant differences in the incidence of ED were observed according to the type of myocardial infarction or left ventricular ejection fraction. The mean IIEF-5 score in the entire population was 18.7 ±5.4 and was significantly lower in patients with ED than in those without ED (14.9 ±4.2 vs. 24.1 ±2.6; p < 0.001). In univariate analysis, age (OR = 1.07 per year; 95% CI: 1.04–1.10; p < 0.001) and diabetes mellitus (OR = 2.20; 95% CI: 1.20–4.10; p = 0.01) were significantly associated with ED. Other variables, including hypertension, type of myocardial infarction, left ventricular ejection fraction, and discharge pharmacotherapy (β-blockers, ACE inhibitors/ARBs, and nitrates), were not significantly associated with ED. In multivariable analysis, age (OR = 1.06 per year; 95% CI: 1.03–1.09; p < 0.001) and diabetes mellitus (OR = 2.10; 95% CI: 1.10–4.00; p = 0.02) remained independently associated with ED.
Table I
Clinical characteristics and patient-reported outcomes in the study population
Sexual activity was resumed after hospital discharge in 82 (41.0%) patients. Patients who resumed sexual activity had higher IIEF-5 scores than those who remained sexually inactive (22.1 ±3.6 vs. 15.4 ±5.1; p < 0.001), and resumption of sexual activity was less frequent in patients with ED (28% vs. 59%; p < 0.001). High levels of fear of sexual activity were reported by 86 (43.0%) patients and were more common among those with ED (52% vs. 30%; p = 0.003). Survey data revealed significant deficiencies in sexual health counseling upon discharge from the hospital; 61 (30.5%) patients recalled information about the possibility of safely resuming sexual activity, while only 27 (13.5%) reported discussing the safety of PDE5 inhibitors in the context of concomitant nitrate therapy. No patients reported the use of phosphodiesterase type 5 inhibitors during the follow-up period.
The multivariable model demonstrated moderate discriminatory power (AUC = 0.74; 95% CI: 0.67–0.81). In the same multivariable model, high anxiety remained significantly associated with the presence of ED after adjusting for age and diabetes (OR = 2.36; 95% CI: 1.28–4.34; p = 0.006) and was also associated with a lower likelihood of resuming sexual activity (31% vs. 52%; p = 0.004). The prevalence of ED increased with age and was 38% in the < 55-year-old group, 54% in the 55–64-year-old group, 67% in the 65–74-year-old group, and 79% in patients ≥ 75 years of age (p for trend < 0.001).
Discussion
This study assessed the prevalence of ED in men in the early period after myocardial infarction treated with percutaneous coronary intervention and analyzed its association with selected clinical characteristics and the scope of sexual health counseling. While the association between ED and traditional risk factors such as age and diabetes is well established, an important contribution of the present study is the identification of substantial gaps in sexual health counseling after myocardial infarction, highlighting an underrecognized aspect of post-discharge care. The obtained results indicate that ED is a common problem in this patient population and coexists with a greater degree of anxiety about sexual activity. At the same time, the observed gaps in discharge counseling regarding the return to sexual activity and the safety of phosphodiesterase type 5 inhibitors in the context of nitrate therapy suggest a significant gap in everyday clinical practice. ED can also be considered an early marker of generalized endothelial dysfunction and vascular disease. The prevalence of ED observed in our study (59%) is similar to the results of previous analyses of patients after myocardial infarction. In a meta-analysis of 428 patients, Sama et al. showed that the cumulative incidence of de novo ED after a first myocardial infarction was approximately 64.4% (95% CI: 44.0–85.0). The results obtained within 4–12 weeks after PCI confirm the early occurrence of this problem in the post-infarction period. Similar findings were reported by Karabay et al., who in a prospective study of patients after STEMI observed an increased incidence of ED in the first months after PCI, with a significant deterioration in the IIEF-EFD scale (p < 0.001). Mild and moderate forms of ED predominated in the analyzed population, and the mean IIEF-5 scale values were comparable to the results of other European studies [6, 11].
Analysis of clinical factors revealed a significant association of ED with age and diabetes. Notably, the strength of association observed for diabetes mellitus was higher than that for age, suggesting a particularly important role of metabolic factors in the development of ED in this population. These results are consistent with the findings of Karabay et al., who, in a multivariate analysis, found older age and diabetes to be significant predictors of worsening erectile function after STEMI. A meta-analysis by Dilixiati et al., including 66,925 diabetic patients, confirmed an increased risk of ED in diabetic patients through vascular and neuropathic mechanisms. In our study, no significant association was observed between hypertension and the occurrence of ED; nor were there differences based on the type of myocardial infarction or left ventricular ejection fraction. These findings may indicate a multifactorial nature of ED in the post-MI period and its association with generalized vascular dysfunction and the presence of comorbidities [12, 13]. Beyond traditional risk factors, erectile function in patients with coronary artery disease is closely related to overall cardiovascular performance, endothelial function, and autonomic regulation. Previous studies have demonstrated a significant association between exercise capacity and erectile function, suggesting that impaired physical fitness may contribute to the severity of ED. Moreover, participation in cardiac rehabilitation programs has been shown to improve erectile function, likely through mechanisms involving improved endothelial function, increased physical capacity, and favorable modulation of autonomic balance. These findings provide important physiological context for our results and support the potential role of cardiac rehabilitation in improving sexual health outcomes in patients after myocardial infarction [14–16].
Another significant phenomenon observed was the relatively low percentage of patients resuming sexual activity in the first weeks after myocardial infarction and the high level of anxiety associated with such activity. In the study population, 41% of patients resumed sexual activity, while 43% reported a high level of anxiety prior to intercourse. This finding should be interpreted in the context of psychological factors affecting sexual activity after myocardial infarction. Steinke et al. reported that patients after myocardial infarction frequently experience fear of recurrent cardiac events and uncertainty regarding the safety of sexual activity [17]. These observations are consistent with broader evidence on psychological distress following myocardial infarction. In a recent systematic review and meta-analysis by Chong et al., the pooled prevalence of depression after acute myocardial infarction was approximately 23.6%, with substantial rates of anxiety and post-traumatic stress disorder. Furthermore, as emphasized in the American Heart Association scientific statement by Levine et al., up to half of patients may experience post-myocardial psychological distress, which has been associated with an increased risk of adverse cardiovascular outcomes through behavioral mechanisms, including reduced physical activity, lower medication adherence, and decreased participation in cardiac rehabilitation programs [18, 19].
This highlights the importance of addressing psychological aspects as part of comprehensive post-myocardial infarction care. Similar observations were reported by Lindau et al., indicating that many post-myocardial infarction patients experience significant concerns about the safety of sexual intercourse. The American Heart Association consensus developed by Steinke et al. emphasizes that anxiety and lack of appropriate education are the main barriers to returning to sexual activity after cardiovascular events. The results of this study also indicate significant gaps in post-hospital sexual health counseling: only about one-third of patients recalled a discussion regarding the safe return to intercourse, and an even smaller percentage were aware of the potential interactions of PDE5 inhibitors with nitrates. Notably, none of the patients reported the use of PDE5 inhibitors during the follow-up period, which may further reflect insufficient counseling and persistent concerns regarding the safety of sexual activity after myocardial infarction. In light of current guidelines, these observations indicate the need to incorporate sexual counseling into standard care for patients after myocardial infarction [16, 20]. The study’s strengths include the relatively large sample size and the use of a validated erectile function assessment tool (IIEF-5). Limitations include the single-center nature of the study, the assessment of sexual function based on patient self-assessment, and the lack of data on erectile function before myocardial infarction. Additional limitations include the lack of detailed data on specific classes of β-blockers used, as different agents (e.g., non-selective vs. cardioselective) may have varying effects on erectile function, as well as the absence of data on patients’ physical activity levels and participation in cardiac rehabilitation programs, which may influence both erectile function and the resumption of sexual activity.
Conclusions
Erectile dysfunction is a common problem in men in the early period following myocardial infarction treated with percutaneous coronary intervention, affecting more than half of patients in the first weeks after the event. Its occurrence is primarily related to age, comorbidities, and psychological factors, but does not show a significant association with the characteristics of the infarction itself or standard cardiac pharmacotherapy. The observed gaps in counseling regarding the safe return to sexual activity and the use of PDE5 inhibitors indicate the need to incorporate sexual health education into routine care and cardiac rehabilitation programs for patients after myocardial infarction. From a clinical perspective, our findings support the inclusion of structured sexual health counseling in discharge checklists. This should include assessment of sexual activity readiness, education on the safe resumption of sexual activity, and information on the appropriate and safe use of PDE5 inhibitors, including contraindications with nitrates.
