Data mining of the search yielded a total of 42 original papers, including 11 publications as casuistics, 10 autopsy studies, 7 ECG monitoring analyses, and 14 collective studies in retrospective, prospective, and case-crossover analysis. The publications were written over a period from 1932 to 2018 and included a total collective of >180.000 patients or cases.
The selection criteria varied widely; in some cases, patient data from a heterogeneous collective of diverse study groups, such as the MILIS study , MIO study , Caerphilly Study [26,27], SHEEP Study ; SUDS Study [29,30], or Paris-SDEC Study  were recruited and analyzed. In other publications, myocardial infarction [16,17,24,25,28,29,32-39], coronary artery disease [26,27,40], sudden cardiac arrest [30,31], stable angina , or documented shock events in patients with ICD- implantation  were selection criteria.
Gender data were found in 2/3 of the publications [16,17,25,26,28,27,30,32,34-53]. In just under half (approximately 43%) of the cases, it was an exclusively male collective. No sex was reported for a total of 5.126 of the cases. Furthermore, the autopsy collective was not included in the analysis of sex distribution because no sex information was available for the overall collective.
The age distribution in the casuistics showed a range of variation from 20-70 years . In some of the collective studies, age range information was found to be 45-59 years [26,27], 35-76 years , or 36-70 years . The largest age range was 20-92 years . Data on mean age were partially represented. This ranged from 57 years , or 58 years  to 60 years . One publication found age- specific data related to prior cardiovascular disease, which was reported as a mean age of 48.5 years for men with atherosclerotic heart disease and 42.5 years for men without prior cardiac disease .
In one publication, a group-specific indication of mean age was given: 49.6 years for group A, which included patients with unchanged or increased sexual activity after myocardial infarction, and 52.3 years for group B, which included patients with reduced sexual activity after myocardial infarction .
Data on previous cardiovascular disease for the total collective were found in 18 publications [24-27,30,35,36,39,42,45,47,49,51,54-57]. These included 5 autopsy studies [54-58] and 3 publications of case reports [47,49,51]. In both casuistry and autopsy studies, myocardial infarctio [47,57] was found more frequently as a presenting condition compared with angina [45,57], hypertension , hypertensive heart disease , arrhythmias, and heart failure , which occurred as isolated cases. In the autopsy collective of Krauland , a total of 50% of the 1.722 autopsies found a pre-existing cardiovascular disorder that was not described in detail.
In the collective studies, a NYHA classification was sometimes given for the collective [35,36,42]. Drory et al.,  and Drory et al.,  listed 50 of 88 men (57%) as having NYHA I, 26 men (30%) as having NYHA II, and 12 men (14%) as having NYHA III. Fries et al.,  classified 28 men as having NYHA I or II and 15 men as having NYHA III. In 3 publications of the collective studies, prior cardiovascular disease was reported in association with sexual frequency [26,27,39]. Smith et al.,  quantified pre-existing heart disease in 918 patients as prevalence per 100, depending on sexual activity. In the low sexual frequency categories it was 20.5% and in the high sexual frequency category it was 14.1%. Ebrahim et al.,  reported pre- existing ECG relevant ischemia for 11 of 914 patients with low sexual frequency (<1x/month) and angina for 16 patients. In comparison in the high sexual frequency category (≥2x/week) there were 5 patients with ECG relevant ischemia and 12 patients with angina. Rothenbacher et al.,  categorized pre-existing cardiovascular disease in 536 patients according to the graduation of coronary heart disease related to sexual activity. In the category of none/low sexual activity (0/<1x/month) there were 35.2% with a 3-vessel-disease. In comparison in the high sexual frequency category (≥1x/week), there were 20.3% with a 3-vessel-disease. Tofler et al.,  listed 204 of 849 patients with angina during the 3 weeks prior to myocardial infarction. Muller et al.,  identified 192 of 858 sexually active patients as having pre- existing myocardial infarction and 186 patients as having pre-existing angina. Aro et al.,  reported 34 patients with sexually triggered heart failure, 8 cases of heart failure and 9 cases of coronary artery disease as pre-existing conditions.
Fatal and nonfatal cardiac/cardiovascular events
Data on fatal events related to sexual activity were found in 19 publications [29-31,43-47,49-55,57-61]. Data came from casuistics [43,44,45,47,49,50-52], autopsy studies [54,55,57-61] and collective studies [29-31,53].
Data on nonfatal events related to sexual activity were found in 17 publications [16,24,25,27,28,31-37,39,40,42,46,48]. The data came from casuistry [46,48], collective studies [16,24,25,27,28,31,37,39,42] or were collected via ECG monitoring [32-36,40,41] of a patient population (Table 1).
Number of cases
Coital cardiovascular events/deaths
11 Publications with casuistics
1/1 bilateral mitral valve prolapse
Safi et al., 
1/1 sinus tachycardia and ventricular tachycardia
2/3 syphilitic vascular changes
2/2 myocardial infarctions
2/2 coronary heart diseases
Anders & Tsokos 
3/7 recurrent myocardial infarctions
1/7 acute left heart failure in CMP and post-ICD implantation
1/7 arrhythmia in reactivated myocarditis
1/7 pericardial tamponade during aortic valve replacement in Marfan-syndrome
Zack & Rummel 
1/1 fibromuscular dysplasia of the AV-nodal artery
Bardale & Dhawane 
1/1 vasovagal response to pain
Gips et al., 
1/1 acute cardiac failure in hypertensive CMP
De-Giorgio et al., 
1/1 rupture aortic aneurysm in coarctation.
Mondello et al., 
1/1 arrhythmogenic right ventricular CMP
10 Autopsy studies
15/67 acute heart failures, 9/67 CHD
5/67 dilated CMP, 5/67 syphilitic aortic stenosis
2/67 pericardial tamponades
13/30 coronary stenoses, 11/30 coronary thromboses
3/30 coronary artery ruptures, 2/30 heart failures
1/30 mesaortitis luica
Missliwetz & Kmen 
6/30 CHD, 5/30 acute myocardial infarctions, 5/30 re-infarctions
7/30 calluses in old infarctions, 4/30 cardiac hypertrophy/cardiac fibrosis
Lecomte et al., 
3/43 cardiovascular, unspecified
Lee et al., 
6/14 CHD, 2/14 fibromuscular dysplasias of the AV-nodal artery
15/1400 sudden cardiac deaths, unspecified
Parzeller et al., 
12/39 CHD, 10/39 re-infarctions, 11/39 myocardial infarctions,
3/39 CMP, 1/39 aneurysm dissecans, 1/39 myocarditis
Parzeller et al., 
13/48 CHD, 13/48 re-infarctions, 12/48 myocardial infarctions,
4/48 CMP, 1/48 aneurysm dissecans, 1/48 myocarditis
Parzeller et al., 
20/68 CHD, 15/68 re-infarctions, 13/68 myocardial infarctions,
7/68 CMP, 4/68 aneurysm dissecans, 1/68 myocarditis
Lange et al., 
28/99 CHD, 21/99 myocardial infarctions, 17/99 re-infarctions,
8/99 CMP, 8/99 aortic aneurysm ruptures
2/99 acute heart failures, 1/99 cardiac arrest, 1/99 myocarditis,
1/99 post-myocardial infarction + cocaine intoxication
69 cases gender not defined
Hellerstein & Friedman 
9/48 angina pectoris
4/48 tachycardia + AP
4/14 ST depression + AP
1/14 VES + SVES
Johnston & Fletcher 
4/24 occasional VES
1/24 occasional SVES
1/24 occasional VES + SVES
1/24 occasional VES + couplets
1/24 frequent VES
1/24 frequent VES + couplets
1/24 constant ventricular bigeminus, couplets, frequent VES
1/24 fusion beats
Paolillo et al., 
higher grade VES, unspecified.
19/35 angina pectoris
2/4 SVT, 2/4 sinus tachycardia
Garcia-Barreto et al., 
1/23 VES in decreasing frequency
3/23 SVES in decreasing frequency
Drory et al., 
21/88 silent cardiac ischemia
6/88 symptomatic cardiac ischemia
Drory et al., 
11/88 complex VES
14 Collective studies
5057 patients gender not defined
Kavanagh & Shephard 
20/81 angina pectoris, 6/81 VES
Gupta & Singh 
11/150 tachycardia, 10/150 AP, 4/150 tachycardia + AP
3/150 dyspnea, 3/150 AP + dyspnea
6/150 hyperventilation, 2/150 tachycardia + hyperventilation
Tofler et al., 
<7.8% acute myocardial infarction
Muller et al., 
27/858 myocardial infarctions 2 hrs after SA
Smith et al., 
OR = 1.0 CHD with high SA (age-adjusted)
OR = 2.2 CHD with low SA (age-adjusted)
Ebrahim et al., 
OR = 1.0 fatal CHD with high SA (age-adjusted)
OR = 1.69 fatal CHD with low SA (age-adjusted)
Möller et al., 
5/399 myocardial infarctions 2 hrs after SA
Fries et al., 
Baylin et al., 
8/470 myocardial infarctions 2 hrs after SA
Masoomi et al., 
17/198 chest pain/chest tightness
Reddy et al., 
7/304 cardiac arrests
Aro et al., 
25/4557 tachycardia + ventricular fibrillation
Rothenbacher et al., 
3/438 cardiac events 1 hr after SA
Sharifzadehgan et al., 
17/3028 cardiac arrests
Table 1: Chronological presentation of cardiac/cardiovascular events or deaths from the casuistics, autopsy studies, ECG monitoring studies and collective studies.
Listing of the number of publications, gender-related presentation of cases or collective, if available. Presentation of published studies indicating the time period.
Coital incidents were subdivided into coital events, with numerical listing of the type of events and presentation of coital deaths.
Triggers of cardiovascular events associated with sexual activity
As triggers of coital cardiovascular events have been identified physical and emotional stress , medical intervention, extreme temperatures, heavy alcohol consumption, toilet use and smoking , decreased physical fitness , alcohol consumption and stress during long car trips , arterial hypertension, obesity, overheating from sun exposure, physical exertion and psychological stress , high body mass index and physical or emotional stress , physical overexcitation, vascular sclerosis and hypertrophic heart disease combined with alcohol consumption , change in familiar environment, extramarital relationship and intense lovemaking and a large age difference [41,56,59], sumptuous meals  and additional stress .
Protective factors and modifying triggers
Protective factors of coital cardiovascular events have been identified as physical conditioning [25,28,37,40] high sexual frequency [26,27,39], prophylactic use of nitroglycerin or/and ß-blockers , warmed up bedrooms, preheated bed sheets, avoidance of sexual intercourse immediately after eating or bathing . For example, in physically fit patients (≥3x/week physical activity/≥6 METs), there is a 2.5-fold decreased relative risk of myocardial infarction associated with sexual activity compared with less physically active patients (≤1x/week physical activity) . In patients with regular sexual contact (≥2x/week), up to a 2.2-fold lower odds ratio for fatal coronary heart disease is outlined compared with patients with lower sexual contact (<1x/month) .
Other triggers of cardiovascular events
Other triggers of cardiovascular events have been cited in isolated cases as walking, activities at work, sedentary office work, driving, domestic quarrels and dinner with family . Furthermore, physical activity [16,24,29,31,38,42,63], occupational activity [40,63], gardening , athletic activity [31,63], rest , sleep [29,34], emotional stress [24,29,38], sleep deprivation, excessive food intake , ergometric testing [35,36], opium use, cigarette use, cold environment, receiving bad news , verbal argument, physical altercation, extreme anxiety, police interrogation situation  were indicated.
Accompanying circumstances of cardiovascular events associated with sexual activity
Casuistics included data on heterosexual activity by men [43-45,47,49,50] and women [43,51-53]. Men’s sexual contacts were mostly with prostitutes [43,44,47,50] and in isolated cases with their steady life partner or wife . Women’s sexual contact was mostly with their steady life partner or husband [43,45,49,53] and in isolated cases with their lover . Autoeroticism [45,47] or zoophilia  were described in one case each among the men. In the autopsy studies, the majority of deaths occurred during extramarital sexual contact: 41/67 cases , 23/30 cases , 21/30 cases , 10/14 cases , 29/68 cases , 41/99 cases .
Less common death events included masturbation: 4/67 cases , 1/30 cases , 3/30 cases , 10/68 cases . Lange et al.,  reported causes of death related to autoerotic activities in nearly 1/3 of cases (30/99). Evidence here was pornographic magazines next to the body. Also rare were oral sexual practices: 1/30 cases , 3/68 cases , 3/99 cases  and homosexual contacts: 4/30 cases , 3/43 cases , 3/48 cases , 5/99 cases . Collective studies assessed data from patients with conjugal heterosexual interaction [16,35,36,40]. Percentage status data were listed in 2 publications: married was 78.2% , and 67.2%  of sexually active patients, respectively.
Data on masturbation were described in one case. Johnston & Fletcher  reported a woman who developed cardiac arrhythmias from masturbating twice with a vibrator.
Place of death
Casuistics reported the locations of death as the hotel room [43,49], the prostitute’s house [44,47,50], one’s home [45,47,53], the stable building of one’s yard property , one’s car [45,51]. In the autopsy studies, the places of death were the hotel in 34/67 cases , 9/30 cases , 10/14 cases , 3/68 cases , 4/99 cases , the brothel in 8/30 cases , 1/14 cases , 21/68 cases , 31/99 cases , the lover’s house in 6/67 cases , 2/14 cases , 5/68 cases , the prostitute’s house 6/68 cases . Lange et al.,  reported the prostitute's or lover’s home as the location of finding in 6/99 cases.
Coital deaths occurred in the prostitute's house: 24/67 cases , 15/30 cases , 12/30 cases , 1/14 cases , 16/68 cases . Less frequently, the car was reported 1/30 cases , 2/30 cases , 1/99 cases , the forest 1/30 cases , or outdoors 2/30 cases . Other rare locations were the porn cinema 3/43 cases , the parking lot 4/99 cases , building or garage in 2/99 cases , the massage parlor in 1/99 cases , or the ambulance in 1/99 cases .