Regrettably, there are relatively limited scientific data on the cardiovascular demands and potential risks of sexual activity in patients with heart disease, some of it dating back 3 or 4 decades and nearly all of it dealing with men. In general, sexual activity is equivalent to mild to moderate physical activity requiring 3 to 5 METs (ie, the equivalent of climbing 2 flights of stairs or walking briskly).482 The few available studies suggest that AMI within 1 to 2 hours of sexual activity is associated with an average RR of 2.7 among middle-aged men, with the greatest risk among those who are sedentary.483 486 Because the overall incidence of AMI is low in the population and periods of exposure relatively infrequent, it has been postulated that the absolute risk is exceedingly low for any individual.487 How- ever, ECG monitoring during sexual activity in 1 study of men with IHD revealed that nearly a third developed ST depression and nearly half developed arrhythmias. It ap- peared, however, that these findings also were found during similarly stressful activities that did not involve sex, and the arrhythmias were largely benign. Moreover, these patients were not initially on anti-ischemic medications, and it was reported that the ischemic changes on ECG resolved when subjects took beta blockers. Thus, it seems that sexual activity should not necessarily be regarded as appreciably different from other types of physical activity that impose equivalent metabolic demands. Needless to say, patients should be treated to maximize their capacity for physical activity, as described subsequently in this guideline. Patients often express concerns that medications given to treat symptoms or reduce cardiovascular risk could cause erectile dysfunction. 