Coronary heart disease is the major cause of morbidity and mortality in the elderly population in the United States, affecting both men and women. Advances in cardiac therapies have enabled cardiac patients to remain both physically and sexually active even into their eighties and nineties. However, both patients and physicians are reluctant to discuss sexual issues. A significant number of patients will have sexual dysfunction following a diagnosis of cardiovascular disease. It is therefore imperative that physicians initiate discussions regarding sexual activity and potential risks to the patient such as myocardial infarction, sudden death, and arrhythmia. Risk stratification based on objective criteria and in particular cases, functional testing, may be useful in counseling patients regarding individual risk. Newly available pharmacologic therapies such as sildenafil may be useful, but must be used with caution in patients with known cardiovascular disease.