Sexual Activity and Cardiovascular Disease

Abstract

HomeCirculationVol. 125, No. 8Sexual Activity and Cardiovascular Disease Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBSexual Activity and Cardiovascular DiseaseA Scientific Statement From the American Heart Association Glenn N. Levine, MD, FAHA, Elaine E. Steinke, RN, PhD, FAHA, Faisal G. Bakaeen, MD, Biykem Bozkurt, MD, PhD, FAHA, Melvin D. Cheitlin, MD, FAHA, Jamie Beth Conti, MD, Elyse Foster, MD, FAHA, Tiny Jaarsma, RN, PhD, FAHA, Robert A. Kloner, MD, PhD, Richard A. Lange, MD, MBA, FAHA, Stacy Tessler Lindau, MD, Barry J. Maron, MD, Debra K. Moser, DNSc, RN, FAHA, E. Magnus Ohman, MD, Allen D. Seftel, MD and William J. Stewart, MD Glenn N. LevineGlenn N. Levine Search for more papers by this author , Elaine E. SteinkeElaine E. Steinke Search for more papers by this author , Faisal G. BakaeenFaisal G. Bakaeen Search for more papers by this author , Biykem BozkurtBiykem Bozkurt Search for more papers by this author , Melvin D. CheitlinMelvin D. Cheitlin Search for more papers by this author , Jamie Beth ContiJamie Beth Conti Search for more papers by this author , Elyse FosterElyse Foster Search for more papers by this author , Tiny JaarsmaTiny Jaarsma Search for more papers by this author , Robert A. KlonerRobert A. Kloner Search for more papers by this author , Richard A. LangeRichard A. Lange Search for more papers by this author , Stacy Tessler LindauStacy Tessler Lindau Search for more papers by this author , Barry J. MaronBarry J. Maron Search for more papers by this author , Debra K. MoserDebra K. Moser Search for more papers by this author , E. Magnus OhmanE. Magnus Ohman Search for more papers by this author , Allen D. SeftelAllen D. Seftel Search for more papers by this author and William J. StewartWilliam J. Stewart Search for more papers by this author and on behalf of the American Heart Association Council on Clinical Cardiologyand Council on Cardiovascular Nursingand Council on Cardiovascular Surgery and Anesthesia, and Council on Quality of Care and Outcomes Research Originally published19 Jan 2012https://doi.org/10.1161/CIR.0b013e3182447787Circulation. 2012;125:1058–1072Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 IntroductionSexual activity is an important component of patient and partner quality of life for men and women with cardiovascular disease (CVD), including many elderly patients.1 Decreased sexual activity and function are common in patients with CVD and are often interrelated to anxiety and depression.2,3 The intent of this American Heart Association Scientific Statement is to synthesize and summarize data relevant to sexual activity and heart disease in order to provide recommendations and foster physician and other healthcare professional communication with patients about sexual activity. Recommendations in this document are based on published studies, the Princeton Consensus Panel,4,5 the 36th Bethesda Conference,6–10 European Society of Cardiology recommendations on physical activity and sports participation for patients with CVD,11–13 practice guidelines from the American College of Cardiology/American Heart Association14–16 and other organizations,17 and the multidisciplinary expertise of the writing group. The classification of recommendations in this document are based on established ACCF/AHA criteria (Table).Table. Applying Classification of Recommendation and Level of EvidenceTable. Applying Classification of Recommendation and Level of EvidenceA recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use.†For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.Acute Cardiovascular Effects of Sexual ActivityNumerous studies have examined the cardiovascular and neuroendocrine response to sexual arousal and intercourse, with most assessing male physiological responses during heterosexual vaginal intercourse.18–24 During foreplay, systolic and diastolic systemic arterial blood pressure and heart rate increase mildly, with more modest increases occurring transiently during sexual arousal. The greatest increases occur during the 10 to 15 seconds of orgasm, with a rapid return to baseline systemic blood pressure and heart rate thereafter. Men and women have similar neuroendocrine, blood pressure, and heart rate responses to sexual activity.24,25Studies conducted primarily in young married men showed that sexual activity with a person's usual partner is comparable to mild to moderate physical activity in the range of 3 to 4 metabolic equivalents (METS; ie, the equivalent of climbing 2 flights of stairs or walking briskly26) for a short duration. Heart rate rarely exceeds 130 bpm and systolic blood pressure rarely exceeds 170 mm Hg4,18,27 in normotensive individuals. However, one study of normotensive men demonstrated substantial variations in peak heart rate and systemic blood pressure during orgasm.23 Because most of the studies that assessed the cardiovascular effects of sexual activity were conducted in healthy men who were young to middle-aged, equating the myocardial oxygen demand of intercourse to climbing 2 flights of stairs is a generalization that may not characterize all individuals, especially those who are older, are less physically fit, or have CVD.18 Therefore, it is probably more reasonable to state that sexual activity is equivalent to mild to moderate physical activity in the range of 3 to 5 METS, taking into account the individual's capacity to perform physical activity. Some patients, particularly older people,1 may have difficulty reaching an orgasm for medical or emotional reasons. In attempting to achieve a climax, it is possible that such individuals may exert themselves to a greater degree of exhaustion with relatively greater demand on their cardiovascular system (although specific data on this are lacking).Sexual Activity and Cardiovascular RiskSexual Activity and AnginaCoital angina (“angina d'amour”), angina that occurs during the minutes or hours after sexual activity, represents <5% of all anginal attacks.28 It is rare in patients who do not have angina during strenuous physical exertion and more prevalent in sedentary individuals with severe coronary artery disease (CAD) who experience angina with minimal physical activity. If a patient can achieve an energy expenditure of ≥3 to 5 METs without demonstrating ischemia during exercise testing, then the risk for ischemia during sexual activity is very low.29Sexual Activity and Myocardial InfarctionMeta-analysis of 4 case-crossover studies, which consisted of 50% to 74% males predominantly in their 50s and 60s, showed that sexual activity was associated with a 2.70 increased relative risk of myocardial infarction (MI) compared with periods of time when the subjects were not engaged in sexual activity (Figure).30 The relative risk of MI does not appear to be higher in subjects with a history of MI than in those without prior known CAD.31 Sedentary individuals have a relative risk of coital MI of 3.0, whereas physically active individuals have a relative risk of 1.2.31 The Stockholm Heart Epidemiology Programme (SHEEP) study of post-MI patients (50% women) similarly found that those who were sedentary had a higher risk of MI with sexual activity (relative risk 4.4) than did those who were physically active (relative risk 0.7).32Download figureDownload PowerPointFigure. Forest plot of case-crossover studies assessing the association of sexual activity with myocardial infarction. CI indicates confidence interval. Modified from Dahabreh et al 30 with permission of the publisher. Copyright © 2011, American Medical Association. All rights reserved.30Although sexual activity is associated with an increased risk of cardiovascular events, the absolute rate of events is miniscule because exposure to sexual activity is of short duration and constitutes a very small percentage of the total time at risk for myocardial ischemia or MI. Sexual activity is the cause of <1% of all acute MIs.31 The absolute risk increase for MI associated with 1 hour of sexual activity per week is estimated to be 2 to 3 per 10 000 person-years.30 Individuals with higher habitual sexual activity levels experience smaller increases in risk than individuals with low activity levels. For the individual with a previous MI, the annual risk of reinfarction or death is estimated to be 10% (or as low as 3% if the individual has good exercise tolerance).33 In such individuals, engaging in sexual activity transiently increases the risk of reinfarction or death from 10 chances in 1 million per hour to 20 to 30 chances in 1 million per hour.31Sexual Activity and Ventricular Arrhythmias/Sudden DeathIn an autopsy report of 5559 instances of sudden death, 34 (0.6%) reportedly occurred during sexual intercourse.34 Two other autopsy studies reported similarly low rates (0.6%–1.7%) of sudden death related to sexual activity.35,36 Of the subjects who died during coitus, 82% to 93% were men, and the majority (75%) were having extramarital sexual activity, in most cases with a younger partner in an unfamiliar setting and/or after excessive food and alcohol consumption. The increase in absolute risk of sudden death associated with 1 hour of additional sexual activity per week is estimated to be <1 per 10 000 person-years.30There are minimal data on the effect of sexual activity in patients with or at risk for ventricular arrhythmias. In a study of post-MI patients, sexual activity did not elicit an increase in ventricular ectopic activity compared with other activities.37 In another report, the frequency of ventricular ectopy and other dysrhythmias was less during sexual activity than during standard exercise testing in male post-MI patients.38 In a small study of 43 patients (8 females) with an internal cardioverter-defibrillator (ICD), the relative risk of tachyarrhythmic events was comparable during physical exertion, mental stress, and sexual activity.39Sexual Activity and CVD: General RecommendationsWomen with CVD should be counseled regarding the safety and advisability of contraceptive methods and pregnancy when appropriate (Class I; Level of Evidence C).It is reasonable that patients with CVD wishing to initiate or resume sexual activity be evaluated with a thorough medical history and physical examination (Class IIa; Level of Evidence C).Sexual activity is reasonable for patients with CVD who, on clinical evaluation, are determined to be at low risk of cardiovascular complications (Class IIa; Level of Evidence B).30–32,40Exercise stress testing is reasonable for patients who are not at low cardiovascular risk or have unknown cardiovascular risk to assess exercise capacity and development of symptoms, ischemia, or arrhythmias (Class IIa; Level of Evidence C).Sexual activity is reasonable for patients who can exercise ≥3 to 5 METS without angina, excessive dyspnea, ischemic ST-segment changes, cyanosis, hypotension, or arrhythmia (Class IIa; Level of Evidence C).5Cardiac rehabilitation and regular exercise can be useful to reduce the risk of cardiovascular complications with sexual activity for patients with CVD (Class IIa; Level of Evidence B).31,41Patients with unstable, decompensated, and/or severe symptomatic CVD should defer sexual activity until their condition is stabilized and optimally managed (Class III; Level of Evidence C).Patients with CVD who experience cardiovascular symptoms precipitated by sexual activity should defer sexual activity until their condition is stabilized and optimally managed (Class III; Level of Evidence C).Men and women with stable CVD who have no or minimal symptoms during routine activities can engage in sexual activity. This includes patients with (1) Canadian Classification System class I or 2 angina; (2) New York Heart Association (NYHA) class I or II heart failure; (3) mild to moderate valvular disease; (4) no symptoms after MI; (5) successful coronary revascularization; (6) most types of congenital heart disease (CHD); and (7) ability to achieve ≥3 to 5 METS during exercise stress testing without angina, ischemic electrocardiographic changes, hypotension, cyanosis, arrhythmia, or excessive dyspnea. In patients with unstable or decompensated heart disease (ie, unstable angina, decompensated heart failure, uncontrolled arrhythmia, or significantly symptomatic and/or severe valvular disease), sexual activity should be deferred until the patient is stabilized and optimally managed. In patients whose exercise capacity or cardiovascular risk is unknown, exercise stress testing can be useful to assess exercise capacity and development of symptoms, ischemia, cyanosis, hypotension, or arrhythmias.Exercise training during cardiac rehabilitation has been shown to increase maximum exercise capacity and decrease peak coital heart rate.41 Regular exercise is associated with a decreased risk of sexual activity–triggered MI.31 Thus, cardiac rehabilitation and regular exercise are reasonable strategies in patients with stable CVD who plan to engage in sexual activity.In addition to the physical demands of sexual activity, the safety and advisability of contraceptive methods and pregnancy should be considered in women with CVD, especially those with CHD, valvular heart disease, or dilated cardiomyopathy.42 Combination hormonal oral contraceptives increase the risk of thromboembolic complications, and recommendations for their use in various cardiovascular conditions have been published.42 Pregnancy is associated with physiological changes that may adversely affect women with certain cardiac conditions and is of particular concern for those undergoing anticoagulation therapy with warfarin because it poses a risk to the fetus (ie, teratogenicity) and mother (ie, bleeding). Conversely, inadequate anticoagulation may lead to complications such as acute prosthetic valve thrombosis and thromboembolism.Sexual Activity and Specific Cardiovascular ConditionsCoronary Artery DiseaseRecommendationsSexual activity is reasonable for patients with no or mild angina (Class IIa; Level of Evidence B).30–32,40Sexual activity is reasonable 1 or more weeks after uncomplicated MI if the patient is without cardiac symptoms during mild to moderate physical activity (Class IIa; Level of Evidence C).Sexual activity is reasonable for patients who have undergone complete coronary revascularization (Class IIa; Level of Evidence B)30–32,40 and may be resumed (a) several days after percutaneous coronary intervention (PCI) if the vascular access site is without complications (Class IIa; Level of Evidence C) or (b) 6 to 8 weeks after standard coronary artery bypass graft surgery (CABG), provided the sternotomy is well healed (Class IIa; Level of Evidence B).43,44Sexual activity is reasonable for patients who have undergone noncoronary open heart surgery and may be resumed 6 to 8 weeks after the procedure, provided the sternotomy is well healed (Class IIa; Level of Evidence C).For patients with incomplete coronary revascularization, exercise stress testing can be considered to assess the extent and severity of residual ischemia (Class IIb; Level of Evidence C).Sexual activity should be deferred for patients with unstable or refractory angina until their condition is stabilized and optimally managed (Class III; Level of Evidence C).Stable Ischemic Heart DiseaseFor patients with stable ischemic heart disease, evaluation of their cardiovascular risk before they initiate or resume sexual activity is reasonable. Patients with mild, stable angina are considered to be at low risk for cardiovascular events, whereas those with unstable or refractory angina are considered to be at high risk.4,5 For patients whose symptoms are intermediate or whose risk cannot be determined during initial evaluation, exercise testing may (1) provide an objective assessment of exercise tolerance and capacity; (2) determine whether angina occurs with exertion (and at what level of exertion); and (3) assess the severity of ischemia with physical activity.Previous MIPatients with previous MI who are asymptomatic or have no ischemia with stress testing or who have undergone complete coronary revascularization are at low risk for coital MI. Before the routine use of reperfusion therapy, it was recommended that sexual activity be avoided for 6 to 8 weeks after MI. In 2005, the Princeton Conference suggested that post -MI patients who had undergone successful coronary revascularization or had a treadmill test without ischemia could resume sexual activity 3 to 4 weeks after MI.5 In contrast, the 2004 “ACC/AHA Guidelines for the Management of Patients with ST-elevation Myocardial Infarction” condoned sexual activity as early as 1 week after MI in the stable patient.15 Because participation of stable patients in cardiac rehabilitation exercise programs 1 week after MI has proved safe,45 resumption of sexual activity soon after uncomplicated MI seems reasonable in the stable patient who is asymptomatic with mild to moderate physical activity (eg, 3–5 METS).Post-PCIThe cardiovascular risk of sexual activity after PCI is likely related to the adequacy of coronary revascularization. Patients with complete revascularization should be able to resume sexual activity within days of PCI, provided there are no complications related to femoral vascular access. Patients in whom there is reason to suspect a vascular complication should undergo appropriate evaluation before resuming sexual activity. Patients who undergo PCI via radial access should be able to resume sexual activity as early as if not earlier than those who undergo PCI via the femoral access. In patients with incomplete coronary revascularization, exercise stress testing may be of benefit in assessing the extent and severity of residual ischemia.Post-CABG and Noncoronary Open Heart ProceduresCABG and most other heart surgeries (eg, valve repair/replacement) are commonly performed through a median sternotomy, with sternal healing typically complete, or nearly so, 8 weeks after surgery. Because sexual activity may involve considerable stress on the chest and breathing patterns that generate high intrathoracic pressures that could compromise sternal wound healing, it is generally recommended that sexual activity be delayed for 6 to 8 weeks after CABG and noncoronary open heart procedures. Patients who have undergone surgery should be counseled to avoid positions that cause discomfort or put undue stress on the surgical site, particularly in the early postoperative months. Physical vigor in such patients is best reintroduced in a gradual fashion. After successful recovery after CABG, sexual activity is usually resumed and sexual satisfaction is usually maintained for many patients.43,44Minimal access cardiac surgery that involves no or a limited sternotomy may allow earlier resumption of sexual activity. Robot-assisted surgery avoids a sternotomy incision and is an iteration of a less-invasive surgical procedure; patients treated with this procedure may similarly be able to resume sexual activity earlier than those undergoing median sternotomy.CABG usually achieves complete or near-complete revascularization. In those in whom there is reason to believe there is significant incomplete revascularization (or graft failure), stress testing may be of benefit in assessing the extent and severity of residual ischemia.Heart FailureRecommendationsSexual activity is reasonable for patients with compensated and/or mild (NYHA class I or II) heart failure (Class IIa; Level of Evidence B).46–49Sexual activity is not advised for patients with decompensated or advanced (NYHA class III or IV) heart failure until their condition is stabilized and optimally managed (Class III; Level of Evidence C).Hemodynamic, vascular, hormonal, and neurohormonal abnormalities may contribute to the sexual dysfunction that commonly occurs in heart failure patients.50 Approximately 60% to 87% of heart failure patients report sexual problems, including a marked decrease in sexual interest and activity, with one quarter reporting cessation of sexual activity altogether.51–53 Sexual function correlates with symptomatic status (ie, NYHA functional class and 6-minute walk test) but not with ejection fraction.52 Interestingly, many heart failure patients place greater importance on improving quality of life (including sexual activity) than on improving survival.54,55Optimal medical treatment of heart failure patients increases the likelihood of safe and satisfactory sexual activity. Exercise training improves quality of life56 in heart failure patients and may favorably impact their sexual activity.57 Heart failure patients who experience shortness of breath or fatigue during sexual activity can be advised to use a semireclining or “on-bottom” position during coitus, which decreases the level of physical exertion, and to rest if dyspnea occurs.58The safety of sexual activity can reasonably be assumed to be related to the symptomatic severity of heart failure (ie, NYHA class) and whether or not the patient is decompensated (eg, volume overloaded). Studies involving stable heart failure patients have shown that it is safe for such patients to engage in sexual activity.46–49Valvular Heart DiseaseRecommendationsSexual activity is reasonable for patients with mild or moderate valvular heart disease and no or mild symptoms (Class IIa; Level of Evidence C).Sexual activity is reasonable for patients with normally functioning prosthetic valves, successfully repaired valves, and successful transcatheter valve interventions (Class IIa; Level of Evidence C).Sexual activity is not advised for patients with severe or significantly symptomatic valvular disease until their condition is stabilized and optimally managed (Class III; Level of Evidence C).Although recommendations on physical activity in patients with valvular heart disease are available,6,11,14 there are no published studies that specifically address the issue of sexual activity in such patients. Because patients with mild or moderate valve disease can safely participate in physical activities involving light or moderate exertion, it is also reasonable for such patients to engage in sexual activity, presuming that such activity does not precipitate significant cardiovascular symptoms. In patients with severe valvular disease with significant symptoms (or even mild symptoms with severe valvular aortic stenosis), it is prudent to defer sexual activity until medical or surgical treatment addresses these conditions. There is no reason to preclude sexual activity in patients with normally functioning prosthetic valves. The timing of return to sexual activity after surgical valve repair or replacement is discussed above in the section on Post-CABG and Noncoronary Open Heart Procedures.In patients whose symptoms or valve disease severity are indeterminate and in those with asymptomatic severe valvular disease, exercise stress testing may provide an assessment of symptomatic and hemodynamic response to physical activity, as well as the possible precipitation of arrhythmias. It can be particularly helpful in assessing the individual with asymptomatic moderate or severe aortic stenosis and patients with severe valve dysfunction of other types who are asymptomatic. Exercise echocardiography can provide additional information on the physiological response to exercise, including ventricular function, inducible increases in valve gradients, and inducible pulmonary hypertension.The physiological effects of pregnancy are of particular concern in female patients with moderate to severe mitral or aortic stenosis and in those whose valvular lesions have caused symptoms, arrhythmias, pulmonary hypertension, ascending aortic dilation, or significant left ventricular dysfunction or dilation.59 In addition, females with a mechanical prosthetic valve on warfarin therapy should be informed that warfarin poses a risk to the fetus (ie, teratogenicity) and mother (ie, bleeding), whereas inadequate anticoagulation may lead to acute valve thrombosis and thromboembolism.Arrhythmias, Pacemakers, and ICDsRecommendationsSexual activity is reasonable for patients with atrial fibrillation or atrial flutter and well-controlled ventricular rate (Class IIa; Level of Evidence C).Sexual activity is reasonable for patients with a history of atrioventricular nodal reentry tachycardia, atrioventricular reentry tachycardia, or atrial tachycardia with controlled arrhythmias (Class IIa; Level of Evidence C).Sexual activity is reasonable for patients with pacemakers (Class IIa; Level of Evidence C).Sexual activity is reasonable for patients with an ICD implanted for primary prevention (Class IIa; Level of Evidence C).Sexual activity is reasonable for patients with an ICD used for secondary prevention in whom moderate physical activity (≥3–5 METS) does not precipitate ventricular tachycardia or fibrillation and who do not receive frequent multiple appropriate shocks (Level of Evidence C).Sexual activity should be deferred for patients with atrial fibrillation and poorly controlled ventricular rate, uncontrolled or symptomatic supraventricular arrhythmias, and spontaneous or exercise-induced ventricular tachycardia until the condition is optimally managed (Class III; Level of Evidence C).Sexual activity should be deferred in patients with an ICD who have received multiple shocks until the causative arrhythmia is stabilized and optimally controlled (Class III; Level of Evidence C).As discussed above, sudden death is an extremely rare occurrence during sexual activity in the general population. There are limited data on the incidence of arrhythmias induced with sexual activity in patients with a known history of arrhythmia. The risk of ventricular arrhythmia during sexual activity in patients with CVD, including those with an ICD, does not appear to be greater than during comparable physical exertion or exercise testing.38,39 Thus, it is reasonable to recommend that patients with arrhythmias who are considered safe to participate in leisure (or more active) sporting activities are able to participate in sexual activity. These would include patients with (1) atrial fibrillation or atrial flutter and a well-controlled ventricular response; (2) a history of atrioventricular nodal reentrant tachycardia, atrioventricular reentry tachycardia, or atrial tachycardia with controlled arrhythmias; (3) a pacemaker; (4) an ICD implanted for primary prevention who have not received multiple shocks appropriate to the patient's arrhythmia; and (5) an ICD implanted for secondary prevention in whom comparable levels of physical activity do not precipitate ventricular tachycardia or ventricular fibrillation and who do not receive frequent appropriate shocks.4,12,13,60 In patients who have received multiple ICD shocks, it is prudent to first stabilize and optimally control the arrhythmia (and underlying cause) before the patient engages in sexual activity. A history of multiple shocks per se is not necessarily a contraindication to the patient ever engaging in sexual activity.As noted above, the presence of an ICD is not a contraindication for sexual activity, and it is reasonable for most patients with an ICD to continue sexual activity. In the patient with an ICD, partner overprotectiveness and the fear of shock with sexual activity are important concerns for the patient and his or her partner.61,62 Accordingly, sexual activity often decreases after ICD implantation.62–64 The sexual partner is not believed to be at risk from defibrillation if the ICD discharges during sexual activity.61,64 Stress testing may provide reassurance to the patient and spouse or partner that sexual activity is unlikely to precipitate or exacerbate arrhythmia.65 Strategies are available for healthcare specialists to use in counseling ICD patients and their partners,61,64 and an excellent “Cardiology Patient Page” (http://circ.ahajournals.org/content/122/13/e465.long) addresses the concerns of patients and partners.61Congenital Heart DiseaseRecommendationSexual activity is reasonable for most CHD patients who do not have decompensated or advanced heart failure, severe and/or significantly symptomatic valvular disease, or uncontrolled arrhythmias (Class IIa; Level of Evidence C).There are estimated to be more than 1 million CHD patients >21 years of age in the United States. Patients with simple, as well as more complex, disease are at risk for atrial and ventricular arrhythmias, stroke, and rarely coronary ischemia. To date, however, there are only rare reported deaths or strokes during sexual activity in this population. In 1 study, 9% of women with CHD reported symptoms during sexual activity, which included dyspnea, perceived arrhythmia, increased fatigue, or syncope.66 Symptoms were more common in those with severe lesions, worse functional status, or cyanosis. In a survey of me