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ANAHEIM -- Sex is not a significant risk factor for sudden cardiac arrest, but when it does turn lethal, the victim is likely to be an African-American man.

A of 4,557 sudden cardiac arrest (SCA) identified by the Oregon Sudden Unexpected Death Study revealed 34 sudden cardiac arrest cases associated with sexual activity -- 18 of which occurred during coitus and 15 immediately after sexual activity (exact timing could not be confirmed for one case).

"Of the sex-SCA cases, 32 (94.0%) were men. Among men, sex-SCA was responsible for 1.0% of overall SCA burden, compared with 0.1% among women," wrote Aapo L. Aro, MD, PhD, of Cedars-Sinai Medical Center in Los Angeles, and colleagues, in a research letter online in the Journal of the American College of Cardiology. The results were also presented in a poster at the American Heart Association meeting.

Martha Gulati, MD, of the University of Arizona College of Medicine-Phoenix, and editor-in-chief of the American College of Cardiology’s CardioSmart.org, noted that the “risk they estimated is very low risk, so if that state [Oregon] is reflective of the U.S. it seems like [sex] is a very low risk.”

That is an important point because the question from patients is always: “Am I at risk?”

The catchment area for the study was the Portland, Oregon metropolitan area, which had a population of roughly 1 million during the period 2002 through 2015, when the cases were reported.

"Among men, sex-SCA was responsible for 1.0% of overall SCA burden, compared with 0.1% among women," they wrote.

In general, the cases occurred in people who were about 5 years younger (range ages 34-83) than controls and "were more likely to be African American," the authors wrote. Additionally, 29% of the patients had a positive cardiovascular history and 26% had symptomatic heart failure.

“One thing they couldn’t tease out was the frequency of intercourse. If they are having intercourse on a regular basis, are they conditioned?,” Gulati pointed out.

She also noted that doctors are often reluctant to initiate a discussion about sex, and patients are sometimes too nervous to bring it up.

But doctors can reassure patients by explaining exactly how much “work” is involved in sex, she noted. “Most people overestimate how much work they perform [during intercourse]. For most people, it is 2 to 4 [metabolic equivalents] METS, which is a measure of how much oxygen is consumed in any activity — 2 METS is equivalent to walking about 2 miles/hour on a flat surface. Some people at peak orgasm may reach 4-5 METS.”

Gulati said that 5 METS is comparable to the amount of “work” required to perform activities of daily living.

She cautioned that sex may be more likely to trigger SCA “after a heavy meal, or alcohol use, or sex with a non-married partner. For men, this often is a mistress.”

A majority of the Oregon cases presented with ventricular fibrillation or tachycardia (76%), which was a higher rate of shockable rhythms than in SCA cases not associated with sex (45%) and that difference was statistically significant (P<0.001). Nonetheless, only about a third of sex-related arrests received bystander cardiopulmonary resuscitation (CPR).

The authors cautioned that factors other than exertion -- notably medications, stimulants, and alcohol use -- may explain contribute to sex-SCA.

Finally, the authors said a key takeaway from the study is the "importance of bystander CPR for SCA, irrespective of the circumstance." To drive that point home, they noted that although these cases were most likely observed, most did not receive bystander CPR and only six of the 34 survived to hospital discharge.

Gulati, who was not involved in the study, echoed this message noting that bystanders should initiate CPR — chest compressions only — immediately after calling 911.