Reply to ‘Sexual function of patients with heart failure: distinct phenotypes distinct sexual function?’ by Konstantinos Koutsampasopoulos

Thank you for reading and commenting on the paper that was recently published in ESC Heart Failure. Dr Koutsampasopoulos and colleagues comment on the role of ejection fraction (EF) in sexual function, and they question the appropriateness of not taking EF into account in the American Heart Association (AHA) scientific statement on sexual activity and cardiovascular disease in advising on or discouraging sexual activity. To take away any misunderstanding, I first need to stress that it should be clear that specifically for patients with heart failure (HF), the AHA statement writes that ‘sexual activity is reasonable for patients with compensated and/or mild (NYHA class I or II) heart failure and that sexual 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’. It is important to realize that this statement is not stating that patients with HF cannot have sex anymore. But I agree with Dr Koutsampasopoulos that this statement is made without mentioning EF. Indeed, it might be interesting to see how sexual problems or complications due to sexual activity are related to EF. A few studies that describe sexual problems in patients with HF included both patients with HFrEF and HFpEF, and it was found that in univariable analysis, left ventricular ejection fraction is related to sexual function in HF patients; however, in multivariable analysis, this relationship did not stay significant. Patients with HFrEF and HEFpEF are known to differ in several characteristics such as age, gender, and comorbidity, which are aspects to consider when studying sexual activity. However, we have to realize that patients with HF (HFrEF; HFpEF of HFmrEF) can experience problems with sexual function, independent of their EF. But at the same time, we have to consider if the content of our advice should be different and if there are different safety issues to have sex for patients with HFrEF; HFpEF of HFmrEF. To give evidence‐based advice on that data are needed, and these data need to be collected in future. Until that time, the general advice for HF patients from AHA can apply; that is, for people who are not stable or not optimally managed, sexual activity is not advised. However, patients who are stable and optimally managed can have sexual activities within their physical limits.