1
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Cannarella R, Gusmano C, Leanza C, Garofalo V, Crafa A, Barbagallo F, Condorelli RA, Vignera SL, Calogero AE. Testosterone replacement therapy and vascular thromboembolic events: a systematic review and meta-analysis. Asian J Androl 2024; 26:144-154. [PMID: 37921515 PMCID: PMC10919420 DOI: 10.4103/aja202352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/15/2023] [Indexed: 11/04/2023] Open
Abstract
To evaluate the relationship between testosterone replacement therapy (TRT) and arterial and/or venous thrombosis in patients with pre-treatment total testosterone (TT) <12 nmol l -1 , we performed a meta-analysis following the Population Intervention Comparison Outcome model. Population: men with TT <12 nmol l -1 or clear mention of hypogonadism in the inclusion criteria of patients; intervention: TRT; comparison: placebo or no therapy; outcomes: arterial thrombotic events (stroke, myocardial infarction [MI], upper limbs, and lower limbs), VTE (deep vein thrombosis [DVT], portal vein thrombosis, splenic thrombosis, and pulmonary embolism), and mortality. A total of 2423 abstracts were assessed for eligibility. Twenty-four studies, including 14 randomized controlled trials (RCTs), were finally included, with a total of 4027 and 310 288 hypotestosteronemic male patients, from RCTs and from observational studies, respectively. Based on RCT-derived data, TRT did not influence the risk of arterial thrombosis (odds ratio [OR] = 1.27, 95% confidence interval [CI]: 0.47-3.43, P = 0.64), stroke (OR = 1.34, 95% CI: 0.09-18.97, P = 0.83), MI (OR = 0.51, 95% CI: 0.11-2.31, P = 0.39), VTE (OR = 1.42, 95% CI: 0.22-9.03, P = 0.71), pulmonary embolism (OR = 1.38, 95% CI: 0.27-7.04, P = 0.70), and mortality (OR = 0.70, 95% CI: 0.20-2.38, P = 0.56). Meanwhile, when only observational studies are considered, a significant reduction in the risk of developing arterial thrombotic events, MI, venous thromboembolism, and mortality was observed. The risk for DVT remains uncertain, due to the paucity of RCT-based data. TRT in men with TT <12 nmol l -1 is safe from the risk of adverse cardiovascular events. Further studies specifically assessing the risk of DVT in men on TRT are needed.
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Affiliation(s)
- Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
- Glickman Urological & Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Carmelo Gusmano
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
| | - Claudia Leanza
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
| | - Vincenzo Garofalo
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
| | - Andrea Crafa
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
| | - Federica Barbagallo
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
| | - Rosita A Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
| | - Aldo E Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania 95123, Italy
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2
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Nguyen Hoai B, Hoang L, Nguyen Cao T, Pham Minh Q, A Jannini E. Testosterone and aging male, a perspective from a developing country. Aging Male 2023; 26:2223712. [PMID: 37335039 DOI: 10.1080/13685538.2023.2223712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/19/2023] [Accepted: 06/06/2023] [Indexed: 06/21/2023] Open
Abstract
PURPOSE Hypogonadism is associated with a wide range of physical and psychological symptoms that can affect the overall health of men. However, in a developing country, there are several imposing challenges in the diagnosis and treatment of hypogonadism, including a lack of awareness and understanding of the condition among healthcare providers and patients, limited resources and the high cost of treatment. This review aimed to examine the potential benefits and risks of testosterone replacement therapy (TRT) and provides a perspective of a developing country on the topic. MATERIALS AND METHODS A comprehensive literature review was conducted to gather relevant information on the impact of testosterone deficiency on ageing males and the effectiveness of TRT for treating hypogonadism. Published peer-reviewed articles were analyzed to evaluate the benefits and risks of TRT. Additionally, the unique challenges faced in the diagnosis and treatment of hypogonadism in a developing country were considered. RESULTS Testosterone replacement therapy has been shown to be an effective treatment for hypogonadism, particularly in symptomatic men with low testosterone levels. It offers potential benefits such as improvements in symptoms and overall quality of life. However, there are associated risks and side effects that need to be considered. In a developing country, challenges such as limited awareness and understanding of hypogonadism, resource constraints, and high treatment costs pose additional barriers to accessing TRT and comprehensive care. CONCLUSION In conclusion, TRT holds promise as a treatment for hypogonadism, but its implementation and accessibility face significant challenges in a developing country. Addressing these challenges, including raising awareness, allocating resources, and finding cost-effective solutions, is crucial for ensuring that men with hypogonadism in such settings receive appropriate diagnosis and treatment. Further research and efforts are needed to improve the management of hypogonadism in developing countries and optimize the potential benefits of TRT for affected individuals.
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Affiliation(s)
- Bac Nguyen Hoai
- Department of Andrology and Sexual Medicine, Hanoi Medical University's Hospital, Hanoi, Vietnam
| | - Long Hoang
- Department of Urology, Hanoi Medical University's Hospital, Hanoi, Vietnam
| | - Thang Nguyen Cao
- Department of Andrology and Sexual Medicine, Hanoi Medical University's Hospital, Hanoi, Vietnam
| | - Quan Pham Minh
- Department of Andrology and Sexual Medicine, Hanoi Medical University's Hospital, Hanoi, Vietnam
| | - Emmanuele A Jannini
- Chair of Endocrinology and Sexual Medicine (ENDOSEX), University of Rome Tor Vergata, Rome, Italy
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3
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Traish AM. Major cardiovascular disease risk in men with testosterone deficiency (hypogonadism): appraisal of short, medium and long-term testosterone therapy - a narrative review. Sex Med Rev 2023; 11:384-394. [PMID: 37587664 DOI: 10.1093/sxmrev/qead031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/29/2023] [Accepted: 07/04/2023] [Indexed: 08/18/2023]
Abstract
INTRODUCTION Low testosterone (T) levels are associated with obesity, metabolic syndrome, type 2 diabetes mellitus and altered lipid profiles, thus contributing to increased cardiovascular disease risk. Hence T deficiency has a detrimental effect on men's vascular health, quality of life and increased mortality. OBJECTIVES This review aims to present summary of data in the contemporary clinical literature pertaining to the benefits of T therapy in clinical studies with varying durations on vascular health in men with T deficiency. METHODS A Medline search using PubMed and EMBASE was performed using the following key words: "testosterone deficiency," "testosterone therapy," major cardiovascular adverse events", "cardiovascular disease". Relevant studies were extracted, evaluated, and analyzed. We evaluated findings from clinical trials, observational studies and systematic reviews and meta-analyses to develop a comprehensive account of the critical role of T in maintaining vascular health. RESULTS Considerable evidence beginning with studies published in 1940s concomitant with findings from the utmost recent clinical studies suggests a clinical value of T therapy in maintaining vascular health and reducing cardiovascular mortality. The current scientific and clinical evidence demonstrates strong relationship between low circulating T levels and risk of cardiovascular disease and T therapy is deemed safe in men with hypogonadism when given in the physiological range with no apparent harm. CONCLUSION What emerges from the current clinical literature is that, irrespective of the length of study durations, testosterone therapy provides significant health benefits and reduces risk of cardiovascular disease. More important is that data from many observational and registry studies, demonstrated that longer durations of testosterone therapy were associated with greater health benefits and reduced cardiovascular risk. T therapy in men with T deficiency reduces the incidence of major adverse cardiovascular events attributed to improving overall metabolic function.
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Affiliation(s)
- Abdulmaged M Traish
- Department of Biochemistry & Department of Urology, Boston University School of Medicine, Boston, MA 02118, United States
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4
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Zhao H, Li JM, Li ZR, Zhang Q, Zhong MK, Yan MM, Qiu XY. Major adverse cardiovascular events associated with testosterone treatment: a pharmacovigilance study of the FAERS database. Front Pharmacol 2023; 14:1182113. [PMID: 37502210 PMCID: PMC10370495 DOI: 10.3389/fphar.2023.1182113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/28/2023] [Indexed: 07/29/2023] Open
Abstract
Background and purpose: Testosterone is an essential sex hormone in maintaining masculine characteristics, which is prescribed for male hypogonadism as testosterone replacement treatment (TRT). Herein, we investigated long-standing controversies about the association between TRT and major adverse cardiovascular events (MACEs), based on real world adverse event (AE) reports, registered in the Food and Drug Administration Adverse Event Reporting System (FAERS). Methods: Publicly available FAERS data from 1 January 2004 to 31 December 2022 were retrieved from the Food and Drug Administration (FDA) website. The data mining protocol including the reporting odds ratio (ROR) and the Bayesian confidence propagation neural network (BCPNN) was applied to analyze overreporting caused by risk factors and MACEs, including TRT, morbidities, and ages. The ROR and the BCPNN were also applied to investigate the annually developing trend of pharmacovigilance (PV) signals in the real world, retrospectively. Results: A total of 3,057 cases referring to MACEs, with a median age of 57 years old (yo), were identified from 28,921 cases of testosterone users. MACEs related to PV signals have emerged since 2014, including cardiac death, non-fatal myocardial infarction, and non-fatal stroke. Myocardial infarction (MI) (ROR: 9.46; IC025: 3.08), acute myocardial infarction (AMI) (ROR: 16.20; IC025: 3.72), ischemic cardiomyopathy (ROR: 11.63; IC025: 2.20), and cardiomyopathy (ROR: 5.98; IC025: 1.96) were the most significant signals generated, and weaker signals included cardiac failure acute (ROR: 4.01; IC025: 0.71), cardiac arrest (ROR: 1.88; IC025: 0.56), and ventricular fibrillation (VF) (ROR: 2.38; IC025: 0.38). The time-to-onset (TTO) of MACEs was calculated with a median of 246 days for AMI. Conclusion: For myocardial infarction and cardiomyopathy, TRT statistically tended to increase the risk of MACEs, while for cardiac arrhythmia, cardiac failure, and stroke, TRT demonstrated beneficial effects among the population with morbidities, such as testosterone deficiency (TD), diabetes mellitus (DM), and hypertension. MACEs were rare but led to serious outcomes including significant increase in death and disability. Since 2018, and before 2014, reports referring to TRT associated with MACEs were relatively scarce, which indicated that there might be a considerable number of cases that went unrecorded, due to neglection. Health workers and testosterone users might pay more attention to testosterone-induced MACEs.
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Affiliation(s)
- Hui Zhao
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Jun-Min Li
- School of Pharmacy, Fudan University, Shanghai, China
| | - Zi-Ran Li
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Qian Zhang
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Ming-Kang Zhong
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Ming-Ming Yan
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao-Yan Qiu
- Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
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5
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Current Management and Controversies Surrounding Andropause. Urol Clin North Am 2022; 49:583-592. [DOI: 10.1016/j.ucl.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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6
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Testosterone Deficiency as One of the Major Endocrine Disorders in Chronic Kidney Disease. Nutrients 2022; 14:nu14163438. [PMID: 36014945 PMCID: PMC9415930 DOI: 10.3390/nu14163438] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022] Open
Abstract
Reduced testosterone concentration is nowadays thought to be one of the main endocrine disorders in chronic kidney disease (CKD). It is caused by the dysfunction of the hypothalamic-pituitary-gonadal axis. The role of testosterone is multifactorial. Testosterone is responsible not only for reproductive processes, but it is a hormone which increases bone and muscle mass, improves lipid profile, insulin sensitivity, erythropoiesis, reduces blood pressure, and ameliorates mood and perception. The implications of hypogonadism in CKD are infertility and loss of libido, reduction of muscle mass and strength, disorders in bone mineralization, the development of sarcopenia and protein energy wasting (PEW), progression of atherosclerosis, increased visceral adiposity, insulin resistance, and anaemia. Reduced testosterone serum concentrations in CKD are associated with increased mortality rate. Testosterone supplementation improves sexual functions, reduces the level of inflammatory markers and blood pressure, stimulates muscle protein synthesis, improves insulin sensitivity and lipid profile, and increases muscle mass, bone mineral density, and haemoglobin concentration. It positively affects mood and well-being. The modes of testosterone supplementation are intramuscular injections, subcutaneous pellets, and percutaneous methods—patches and gels. Successful kidney transplantation may improve gonadal function and testosterone production, however, half of men with low testosterone concentrations before kidney transplantation do not restore hormonal function.
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7
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Madsen MC, den Heijer M, Pees C, Biermasz NR, Bakker LEH. Testosterone in men with hypogonadism and transgender males: a systematic review comparing three different preparations. Endocr Connect 2022; 11:e220112. [PMID: 35904217 PMCID: PMC9346330 DOI: 10.1530/ec-22-0112] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022]
Abstract
Testosterone therapy is the cornerstone in the care of men with hypogonadism and transgender males. Gel and intramuscular injections are most frequently used and are registered and included in the international guidelines. The specific preparation should be selected according to the patient's preference, cost, availability, and formulation-specific properties. As the majority of men with hypogonadism and transgender males require lifelong treatment with testosterone, it is important to utilize a regimen that is effective, safe, inexpensive, and convenient to use with optimal mimicking of the physiological situation. This systematic review reviews current literature on differences between the three most used testosterone preparations in adult men with hypogonadism and transgender males. Although it appeared hardly any comparative studies have been carried out, there are indications of differences between the preparations, for example, on the stability of testosterone levels, hematocrit, bone mineral density, and patient satisfaction. However, there are no studies on the effects of testosterone replacement on endpoints such as cardiovascular disease in relation to hematocrit or osteoporotic fractures in relation to bone mineral density. The effect of testosterone therapy on health-related quality of life is strongly underexposed in the reviewed studies, while this is a highly relevant outcome measure from a patient perspective. In conclusion, current recommendations on testosterone treatment appear to be based on data primarily from non-randomized clinical studies and observational studies. The availability of reliable comparative data between the different preparations will assist in the process of individual decision-making to choose the most suitable formula.
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Affiliation(s)
- Milou Cecilia Madsen
- Department of Internal Medicine and Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Martin den Heijer
- Department of Internal Medicine and Center of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Claudia Pees
- Walaeus Library, Leiden University Medical Center, Leiden, the Netherlands
| | - Nienke R Biermasz
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Leontine E H Bakker
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
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8
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Shores MM, Walsh TJ, Korpak A, Krakauer C, Forsberg CW, Fox AE, Moore KP, Heckbert SR, Thompson ML, Smith NL, Matsumoto AM. Association Between Testosterone Treatment and Risk of Incident Cardiovascular Events Among US Male Veterans With Low Testosterone Levels and Multiple Medical Comorbidities. J Am Heart Assoc 2021; 10:e020562. [PMID: 34423650 PMCID: PMC8649267 DOI: 10.1161/jaha.120.020562] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Testosterone treatment is common in men, although risks for major cardiovascular events are unclear. Methods and Results A study was conducted in US male veterans, aged ≥40 years, with low serum testosterone and multiple medical comorbidities and without history of myocardial infarction, stroke, venous thromboembolism, prostate cancer, or testosterone treatment in the prior year. For the primary outcome, we examined if testosterone treatment was associated with a composite cardiovascular outcome (incident myocardial infarction, ischemic stroke, or venous thromboembolism). Testosterone use was modeled as intramuscular or transdermal and as current use, former use, and no use. Current testosterone users were compared with former users to reduce confounding by indication. The cohort consisted of 204 857 men with a mean (SD) age of 60.9 (9.9) years and 4.7 (3.5) chronic medical conditions. During follow‐up of 4.3 (2.8) years, 12 645 composite cardiovascular events occurred. In adjusted Cox regression analyses, current use of transdermal testosterone was not associated with risk for the composite cardiovascular outcome (hazard ratio [HR], 0.89; 95% CI, 0.76–1.05) in those without prevalent cardiovascular disease, and in those with prevalent cardiovascular disease was associated with lower risk (HR, 0.80; 95% CI, 0.70–0.91). In similar analyses, current use of intramuscular testosterone was not associated with risk for the composite cardiovascular outcome in men without or with prevalent cardiovascular disease (HR, 0.91; 95% CI, 0.80–1.04; HR, 0.98; 95% CI, 0.89–1.09, respectively). Conclusions In a large cohort of men without a history of myocardial infarction, stroke, or venous thromboembolism, testosterone treatment was not associated with increased risk for incident composite cardiovascular events.
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Affiliation(s)
- Molly M Shores
- Department of Psychiatry and Behavioral Sciences University of Washington Seattle WA.,VA Puget Sound Health Care System (VAPSHCS) Seattle WA
| | - Thomas J Walsh
- Department of Urology University of Washington Seattle WA
| | - Anna Korpak
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA
| | - Chloe Krakauer
- Kaiser Permanente Washington Health Research Institute Seattle WA
| | - Christopher W Forsberg
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA
| | - Alexandra E Fox
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA
| | - Kathryn P Moore
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA
| | - Susan R Heckbert
- Kaiser Permanente Washington Health Research Institute Seattle WA.,Department of Epidemiology University of Washington Seattle WA
| | - Mary Lou Thompson
- Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA.,Kaiser Permanente Washington Health Research Institute Seattle WA.,Department of Biostatistics University of Washington Seattle WA
| | - Nicholas L Smith
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Seattle Epidemiologic Research and Information Center (ERIC) VAPSHCS Seattle WA.,Kaiser Permanente Washington Health Research Institute Seattle WA.,Department of Epidemiology University of Washington Seattle WA
| | - Alvin M Matsumoto
- VA Puget Sound Health Care System (VAPSHCS) Seattle WA.,Department of Medicine University of Washington School of Medicine Seattle WA.,Geriatric Research Education and Clinical Center (GRECC) VAPSHCS Seattle WA
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9
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Lee JH, Shah PH, Uma D, Salvi DJ, Rabbani R, Hamid P. Testosterone Replacement Therapy in Hypogonadal Men and Myocardial Infarction Risk: Systematic Review & Meta-Analysis. Cureus 2021; 13:e17475. [PMID: 34513525 PMCID: PMC8405174 DOI: 10.7759/cureus.17475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 08/26/2021] [Indexed: 01/23/2023] Open
Abstract
Testosterone replacement therapy (TRT) has become increasingly popular over the years and there has been an increasing debate on whether testosterone replacement should be offered to older men due to its association with cardiovascular events. In this study, we evaluated the risk of myocardial infarction (MI) associated with TRT in hypogonadal men through a meta-analysis. We carried out the analysis by following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines and conducted a literature search utilizing the following databases: Google Scholar, PubMed, Science Direct, Cochrane Library trials, and ClinicalTrials.gov. The search strategy resulted in a total of 782 articles, after applying our inclusion and exclusion criteria. Six observational studies and two randomized controlled trials (RCTs) were included for the analysis. A total of 55,806 hypogonadal men with baseline testosterone levels <300ng/mL were included in the analysis. The intervention group received testosterone in various routes including transdermal patches, gels, mouth patches, testosterone injections, and deposits. The incidence of MI was taken to be the primary measure outcomes. The pooled data from eight studies showed MI incidence in 249 out of 11,720 (2.1%) in the TRT group and 1420 out of 33,086 (4.3%) in the control group. The pooled OD showed no statistically significant association of TRT and MI compared to the control group (OR = 0.76, 95% CI 0.36-1.31; p=0.48). The model revealed high heterogeneity with I2 =79%. With sensitivity analysis and, excluding two studies out of the eight, the pooled data was able to achieve low heterogeneity with I2 = 0%. The newly pooled data from six studies showed MI incidence in 226 out of 10,137 (2.2%) in the TRT group and 969 out of 36,304 (2.7%) in the control group. The pooled OD shows no statistical significance in the association between TRT treatment and MI compared to the control group. (OR =0.87, 95% CI 0.75-1.01; P =0.08). It appears that TRT does not increase the risk of MI as compared to the non-intervention group. Further RCTs with greater population size are needed that could produce more solid results, allowing more definitive conclusions to be made on this topic.
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Affiliation(s)
- Jun Hee Lee
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Prutha H Shah
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Davuluri Uma
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Dhairya J Salvi
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rizwan Rabbani
- Nephrology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Pousette Hamid
- Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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10
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Cittadini A, Isidori AM, Salzano A. Testosterone therapy and cardiovascular diseases. Cardiovasc Res 2021; 118:2039-2057. [PMID: 34293112 DOI: 10.1093/cvr/cvab241] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/16/2021] [Indexed: 11/14/2022] Open
Abstract
Since it was first synthesised in 1935, testosterone (T) has been viewed as the mythical Fountain of Youth, promising rejuvenation, restoring sexual appetites, growing stronger muscles, and quicker thinking. T is endowed with direct effects on myocardial and vascular structure and function, as well as on risk factors for cardiovascular (CV) disease. Indeed, low serum T levels are a risk factor for diabetes, metabolic syndrome, inflammation, and dyslipidaemia. Moreover, many studies have shown that T deficiency per se is an independent risk factor of CV and all-cause mortality. On this background and due to direct-to-patient marketing by drug companies, we have witnessed to the widespread use of T replacement therapy (TT) without clear indications particularly in late-life onset hypogonadism. The current review will dwell upon current evidence and controversies surrounding the role of T in the pathophysiology of CV diseases, the link between circulating T levels and CV risk, and the use of replacing T as a possible adjuvant treatment in specific CV disorders. Specifically, recent findings suggest that heart failure and type 2 diabetes mellitus represent two potential targets of T therapy once that a state of hypogonadism is diagnosed. However, only if ongoing studies solve the CV safety issue the T orchid may eventually 'bloom'.
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Affiliation(s)
- Antonio Cittadini
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Interdisciplinary Research Centre on Biomaterials (CRIB), Federico II University, Naples, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea Salzano
- IRCCS SDN, Diagnostic and Nuclear Research Institute, Naples, Italy
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11
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Zhang X, Huang K, Saad F, Haider KS, Haider A, Xu X. Testosterone Therapy Reduces Cardiovascular Risk Among Hypogonadal Men: A Prospective Cohort Study in Germany. ACTA ACUST UNITED AC 2021. [DOI: 10.1089/andro.2020.0015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Xiao Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, Texas, USA
| | - Ke Huang
- Department of Statistics, Texas A&M University, College Station, Texas, USA
- Department of Statistics, University of California, Riverside, California, USA
| | - Farid Saad
- Research Department, Gulf Medical University, Ajman, United Arab Emirates
| | | | | | - Xiaohui Xu
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, Texas, USA
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12
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Costa S, Saguner AM, Gasperetti A, Akdis D, Brunckhorst C, Duru F. The Link Between Sex Hormones and Susceptibility to Cardiac Arrhythmias: From Molecular Basis to Clinical Implications. Front Cardiovasc Med 2021; 8:644279. [PMID: 33681311 PMCID: PMC7925388 DOI: 10.3389/fcvm.2021.644279] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 01/27/2021] [Indexed: 12/30/2022] Open
Abstract
It is well-known that gender is an independent risk factor for some types of cardiac arrhythmias. For example, males have a greater prevalence of atrial fibrillation and the Brugada Syndrome. In contrast, females are at increased risk for the Long QT Syndrome. However, the underlying mechanisms of these gender differences have not been fully identified. Recently, there has been accumulating evidence indicating that sex hormones may have a significant impact on the cardiac rhythm. In this review, we describe in-depth the molecular interactions between sex hormones and the cardiac ion channels, as well as the clinical implications of these interactions on the cardiac conduction system, in order to understand the link between these hormones and the susceptibility to arrhythmias.
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Affiliation(s)
- Sarah Costa
- Arrhythmia and Electrophysiology, Department of Cardiology, University Heart Center, Zurich, Switzerland
| | - Ardan M Saguner
- Arrhythmia and Electrophysiology, Department of Cardiology, University Heart Center, Zurich, Switzerland
| | - Alessio Gasperetti
- Arrhythmia and Electrophysiology, Department of Cardiology, University Heart Center, Zurich, Switzerland.,Cardiac Arrhythmia Service, Department of Cardiology, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Deniz Akdis
- Arrhythmia and Electrophysiology, Department of Cardiology, University Heart Center, Zurich, Switzerland
| | - Corinna Brunckhorst
- Arrhythmia and Electrophysiology, Department of Cardiology, University Heart Center, Zurich, Switzerland
| | - Firat Duru
- Arrhythmia and Electrophysiology, Department of Cardiology, University Heart Center, Zurich, Switzerland.,Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
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Ayele HT, Brunetti VC, Renoux C, Tagalakis V, Filion KB. Testosterone replacement therapy and the risk of venous thromboembolism: A systematic review and meta-analysis of randomized controlled trials. Thromb Res 2021; 199:123-131. [PMID: 33486321 DOI: 10.1016/j.thromres.2020.12.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/22/2020] [Accepted: 12/29/2020] [Indexed: 01/20/2023]
Abstract
INTRODUCTION The cardiovascular safety of testosterone replacement therapy (TRT) is controversial. While several studies have investigated the association between TRT and the risk of arterial thrombosis, limited information is available regarding its risk of venous thromboembolism (VTE). We aimed to compare the risk of VTE in men randomized to TRT versus placebo or active-comparator in a systematic review. METHODS We searched Medline, EMBASE, CINAHL, CENTRAL, and clinical trial registries to identify randomized controlled trials (RCTs) comparing TRT to placebo in men aged ≥18 years. We assessed study quality using the Cochrane Risk of Bias assessment tool and the overall quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Data were pooled across RCTs using random-effects models. RESULTS A total of 13 RCTs (n = 5050) were included in our meta-analysis. In all, 2636 men were randomized to testosterone, and 2414 men to placebo. Sample sizes ranged from 101 to 790 men, and TRT duration from 3 to 36 months. Five studies had a high risk of bias, largely driven by unclear randomization and outcome assessment. When data were pooled across RCTs, testosterone therapy was not associated with VTE compared with placebo (RR: 1.03, 95% CI: 0.49-2.14; I2: 0%; low-quality evidence). Similar estimates were obtained for deep vein thrombosis and pulmonary embolism outcomes. CONCLUSIONS Our systematic review suggests that TRT is not associated with an increased risk of VTE. However, estimates were accompanied by a wide 95% CIs, and a clinically important increased risk cannot be ruled out.
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Affiliation(s)
- Henok Tadesse Ayele
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada.
| | - Vanessa C Brunetti
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada.
| | - Christel Renoux
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
| | - Vicky Tagalakis
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Division of General Internal Medicine, Department of Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, H3T 1E2, Canada.
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, H3T 1E2, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, 3755 Cote Ste-Catherine, Montreal, Quebec, H3T 1E2, Canada; Department of Medicine, McGill University, Montreal, Quebec, Canada.
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Kharaba ZJ, Buabeid MA, Ibrahim NA, Jirjees FJ, Obaidi HJA, Kaddaha A, Khajehkarimoddini L, Alfoteih Y. Testosterone therapy in hypogonadal patients and the associated risks of cardiovascular events. Biomed Pharmacother 2020; 129:110423. [PMID: 32570122 DOI: 10.1016/j.biopha.2020.110423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/06/2020] [Accepted: 06/13/2020] [Indexed: 10/24/2022] Open
Abstract
Since the male secondary sex characters, libido and fertility are attributed to their major androgen hormone testosterone, the sub-optimum levels of testosterone in young adults may cause infertility and irregularities in their sexual behaviour. Such deficiency is often secondary to maladies involving testes, pituitary or hypothalamus that could be treated with an administration of exogenous testosterone. In the last few decades, the number of testosterone prescriptions has markedly increased to treat sub-optimal serum levels even though its administration in such conditions is not yet approved. On account of its associated cardiovascular hazards, the food and drug authority in the United States has issued safety alerts on testosterone replacement therapy (TRT). Owing to a great degree of conflict among their findings, the published clinical trials seem struggling in presenting a decisive opinion on the matter. Hence, the clinicians remain uncertain about the possible cardiovascular adversities while prescribing TRT in hypogonadal men. The uncertainty escalates even further while prescribing such therapy in older men with a previous history of cardiovascular ailments. In the current review, we analysed the pre-clinical and clinical studies to evaluate the physiological impact of testosterone on cardiovascular and related parameters. We have enlisted studies on the association of cardiovascular health and endogenous testosterone levels with a comprehensive analysis of epidemiological studies, clinical trials, and meta-analyses on the cardiovascular risk of TRT. The review is aimed to assist clinicians in making smart decisions regarding TRT in their patients.
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Affiliation(s)
- Zelal Jaber Kharaba
- Department of Clinical Sciences, College of Pharmacy, Al-Ain University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Manal Ali Buabeid
- Department of Clinical Sciences, Ajman University, Ajman, 346, United Arab Emirates
| | - Nihal A Ibrahim
- Department of Clinical Sciences, Ajman University, Ajman, 346, United Arab Emirates
| | | | | | | | | | - Yassen Alfoteih
- City University College of Ajman, Ajman, 18484, United Arab Emirates.
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Boden WE, Miller MG, McBride R, Harvey C, Snabes MC, Schmidt J, McGovern ME, Fleg JL, Desvigne-Nickens P, Anderson T, Kashyap M, Probstfield JL. Testosterone concentrations and risk of cardiovascular events in androgen-deficient men with atherosclerotic cardiovascular disease. Am Heart J 2020; 224:65-76. [PMID: 32335402 DOI: 10.1016/j.ahj.2020.03.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Whether androgen deficiency among men increases the risk of cardiovascular (CV) events or is merely a disease marker remains a subject of intense scientific interest. OBJECTIVES Among male subjects in the AIM-HIGH Trial with metabolic syndrome and low baseline levels of high-density lipoprotein (HDL)-cholesterol who were randomized to niacin or placebo plus simvastatin, we examined the relationship between low baseline testosterone (T) concentrations and subsequent CV outcomes during a mean 3-year follow-up. METHODS In this post hoc analysis of men with available baseline plasma T concentrations, we examined the relationship between clinical/demographic characteristics and T concentrations both as a continuous and dichotomous variable (<300 ng/dL ["low T"] vs. ≥300 ng/dL ["normal T"]) on rates of pre-specified CV outcomes, using Cox proportional hazards models. RESULTS Among 2118 male participants in whom T concentrations were measured, 643 (30%) had low T and 1475 had normal T concentrations at baseline. The low T group had higher rates of diabetes mellitus, hypertension, elevated body mass index, metabolic syndrome, higher blood glucose, hemoglobin A1c, and triglyceride levels, but lower levels of both low-density lipoprotein and HDL-cholesterol, and a lower rate of prior myocardial infarction (MI). Men with low T had a higher risk of the primary composite outcome of coronary heart disease (CHD) death, MI, stroke, hospitalization for acute coronary syndrome, or coronary or cerebral revascularization (20.1%) compared with the normal T group (15.2%); final adjusted HR 1.23, P = .07, and a higher risk of the CHD death, MI, and stroke composite endpoint (11.8% vs. 8.2%; final adjusted HR 1.37, P = .04), respectively. CONCLUSIONS In this post hoc analysis, there was an association between low baseline testosterone concentrations and increased risk of subsequent CV events in androgen-deficient men with established CV disease and metabolic syndrome, particularly for the composite secondary endpoint of CHD death, MI, and stroke. CONDENSED ABSTRACT In this AIM-HIGH Trial post hoc analysis of 2118 men with metabolic syndrome and low HDL-cholesterol with available baseline plasma testosterone (T) samples, 643 males (30%) had low T (mean: 229 ng/dL) and 1475 (70%) had normal T (mean: 444 ng/dL) concentrations. The "low T" group had a 24% higher risk of the primary 5-component endpoint (20.1%) compared with the normal T group (15.2%); final adjusted HR 1.23, P = .07). There was also a 31% higher risk of the secondary composite endpoint: coronary heart disease death, myocardial infarction, and stroke (11.8% vs. 8.2%, final adjusted HR 1.37, P = .04) in the low vs. normal T group, respectively.
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16
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Chung JY, Brown S, Chen H, Liu J, Papadopoulos V, Zirkin B. Effects of pharmacologically induced Leydig cell testosterone production on intratesticular testosterone and spermatogenesis†. Biol Reprod 2020; 102:489-498. [PMID: 31504200 PMCID: PMC7443349 DOI: 10.1093/biolre/ioz174] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/30/2019] [Accepted: 08/26/2019] [Indexed: 12/13/2022] Open
Abstract
The Leydig cells of the mammalian testis produce testosterone (T) in response to luteinizing hormone (LH). In rats and men with reduced serum T levels, T replacement therapy (TRT) will raise T levels, but typically with suppressive effects on sperm formation. The rate-determining step in T formation is the translocation of cholesterol to the inner mitochondrial membrane, mediated by protein-protein interactions of cytosolic and outer mitochondrial membrane proteins. Among the involved proteins is cholesterol-binding translocator protein (TSPO) (18 kDa TSPO). We hypothesized that in contrast to TRT, the administration of the TSPO agonist N,N-dihexyl-2-(4-fluorophenyl)indole-3-acetamide (FGIN-1-27), by stimulating the ability of the Leydig cells to produce T, would result in the elevation of serum T levels while maintaining intratesticular T concentration and therefore without suppression of spermatogenesis. Age-related reductions in both serum and intratesticular T levels were seen in old Brown Norway rats. Both exogenous T and FGIN-1-27 increased serum T levels. With exogenous T, serum LH and Leydig cell T formation were suppressed, and intratesticular T was reduced to below the concentration required to maintain spermatogenesis quantitatively. In contrast, FGIN-1-27 stimulated Leydig cell T formation, resulting in increased serum T without reductions in intratesticular T concentrations or in testicular sperm numbers. FGIN-1-27 also significantly increased serum and intratesticular T levels in rats made LH-deficient by treatment with the gonadotropin-releasing hormone antagonist cetrorelix. These results point to a possible approach to increasing serum T without negative effects on spermatogenesis, based upon stimulating T production by the Leydig cells themselves rather than administering T exogenously.
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Affiliation(s)
- Jin-Yong Chung
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sean Brown
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Haolin Chen
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Anesthesiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - June Liu
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Vassilios Papadopoulos
- Department of Pharmacology and Pharmaceutical Sciences, School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Barry Zirkin
- Department of Biochemistry and Molecular Biology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Abstract
This article contains a systematic review of the main developments that have occurred in the area of male hypogonadism between the publication of the Endocrine Society Guidelines of 2010 and 2018 and after 2018.
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Affiliation(s)
- Marco Marcelli
- Department of Medicine, Division of Endocrinology, Baylor College of Medicine, Houson, Texas, USA .,Section of Endocrinology, Michael E DeBakey VA Medical Center, Houston, Texas, USA
| | - Sanjay Navin Mediwala
- Department of Medicine, Division of Endocrinology, Baylor College of Medicine, Houson, Texas, USA.,Section of Endocrinology, Michael E DeBakey VA Medical Center, Houston, Texas, USA
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Abstract
Testosterone is the main male sex hormone and is essential for the maintenance of male secondary sexual characteristics and fertility. Androgen deficiency in young men owing to organic disease of the hypothalamus, pituitary gland or testes has been treated with testosterone replacement for decades without reports of increased cardiovascular events. In the past decade, the number of testosterone prescriptions issued for middle-aged or older men with either age-related or obesity-related decline in serum testosterone levels has increased exponentially even though these conditions are not approved indications for testosterone therapy. Some retrospective studies and randomized trials have suggested that testosterone replacement therapy increases the risk of cardiovascular disease, which has led the FDA to release a warning statement about the potential cardiovascular risks of testosterone replacement therapy. However, no trials of testosterone replacement therapy published to date were designed or adequately powered to assess cardiovascular events; therefore, the cardiovascular safety of this therapy remains unclear. In this Review, we provide an overview of epidemiological data on the association between serum levels of endogenous testosterone and cardiovascular disease, prescription database studies on the risk of cardiovascular disease in men receiving testosterone therapy, randomized trials and meta-analyses evaluating testosterone replacement therapy and its association with cardiovascular events and mechanistic studies on the effects of testosterone on the cardiovascular system. Our aim is to help clinicians to make informed decisions when considering testosterone replacement therapy in their patients.
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Corona G, Rastrelli G, Di Pasquale G, Sforza A, Mannucci E, Maggi M. Testosterone and Cardiovascular Risk: Meta-Analysis of Interventional Studies. J Sex Med 2019; 15:820-838. [PMID: 29803351 DOI: 10.1016/j.jsxm.2018.04.641] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/09/2018] [Accepted: 04/11/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND The relationship between testosterone (T) and cardiovascular (CV) risk in men is conflicting. AIM To verify whether T therapy (TTh) represents a possible risk factor for CV morbidity and mortality. METHODS We conducted a random effect meta-analysis considering all available data from pharmaco-epidemiological studies as well as randomized placebo-controlled trials (RCTs). OUTCOMES CV mortality and morbidity were investigated. RESULTS After screening, 15 pharmaco-epidemiological and 93 RCT studies were considered. The analysis of pharmaco-epidemiological studies documented that TTh reduces overall mortality and CV morbidity. Conversely, in RCTs, TTh had no clear effect, either beneficial or detrimental, on the incidence of CV events. However, a protective role of TTh on CV morbidity was observed when studies enrolling obese (body mass index >30 kg/m2) patients were scrutinized (Mantel-Haenszel odds ratio 0.51 [95% CI 0.27-0.96]; P = .04), although this association disappeared when only high-quality RCTs were considered (Mantel-Haenszel odds ratio 0.64 [95% CI 0.22-1.88]; P = .42). Finally, an increased risk of CV diseases was observed in RCTs when T preparations were prescribed at dosages above those normally recommended, or when frail men were considered. CLINICAL IMPLICATIONS Pharmaco-epidemiological studies showed that TTh might reduce CV risk, but this effect was not confirmed when RCTs were considered. STRENGTHS & LIMITATIONS Meta-analysis of pharmaco-epidemiological studies indicates that TTh reduces overall mortality and CV morbidity. In addition, even in RCTs, a protective role of TTh on CV morbidity was envisaged when studies enrolling obese (body mass index >30 kg/m2) patients were considered. Pharmaco-epidemiological studies should be considered with caution due to the lack of completeness of follow-up and of the management of missing data. In addition, properly powered placebo-controlled RCTs with a primary CV end point, in men with late-onset hypo-gonadism, are not yet available. Finally, the duration of all studies evaluated in the present meta-analysis is relatively short, reaching a maximum of 3 years. CONCLUSIONS Data from RCTs suggest that treatment with T is not effective in reducing CV risk, however, when TTh is correctly applied, it is not associated with an increase in CV risk and it may have a beneficial effect in some sub-populations. Corona G, Rastrelli G, Di Pasquale G, et al. Testosterone and Cardiovascular Risk: Meta-Analysis of Interventional Studies. J Sex Med 2018;15:820-838.
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Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Giulia Rastrelli
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence, Italy
| | - Giuseppe Di Pasquale
- Cardiology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Alessandra Sforza
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Edoardo Mannucci
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence, Italy; Diabetes Agency, Careggi Hospital, Florence, Italy
| | - Mario Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical, and Biomedical Sciences, University of Florence, Florence, Italy.
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20
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Oni OA, Dehkordi SHH, Jazayeri MA, Sharma R, Sharma M, Masoomi R, Sharma R, Gupta K, Barua RS. Relation of Testosterone Normalization to Mortality and Myocardial Infarction in Men With Previous Myocardial Infarction. Am J Cardiol 2019; 124:1171-1178. [PMID: 31409450 DOI: 10.1016/j.amjcard.2019.07.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 02/04/2023]
Abstract
The effect of normalization of serum testosterone levels with testosterone replacement therapy (TRT) in patients with a history of myocardial infarction (MI) is unknown. The objective of this study was to determine the incidence of recurrent MI and all-cause mortality in subjects with a history of MI and low total testosterone (TT) with and without TRT. We retrospectively examined 1,470 men with documented low TT levels and previous MI, categorized into Gp1: TRT with normalization of TT levels (n = 755) Gp2: TRT without normalization of TT levels (n = 542), and Gp3: no TRT (n = 173). The association of TRT with all-cause mortality and recurrent MI was compared using propensity score-weighted Cox proportional hazard models. All-cause mortality was lower in Gp1 versus Gp2 (hazard ratio [HR] 0.76, confidence interval [CI] 0.64 to 0.90, p = 0.002), and Gp1 versus Gp3 (HR 0.76, CI 0.60 to 0.98, p = 0.031). There was no significant difference in the risk of death between Gp2 versus Gp3 (HR 0.97, CI 0.76 to 1.24, p = 0.81). Adjusted regression analyses showed no significant differences in the risk of recurrent MI between groups (Gp1 vs Gp3, HR 0.79, CI 0.12 to 5.27, p = 0.8; Gp1 vs Gp2 HR 1.10, CI 0.25 to 4.77, p = 0.90; Gp2 vs Gp3 HR 0.58, CI 0.08 to 4.06, p = 0.58). In conclusion, in a large observational cohort of male veterans with previous MI, normalization of TT levels with TRT was associated with decreased all-cause mortality compared with those with non-normalized TT levels and the untreated group. Furthermore, in this high-risk population, TRT was not associated with an increased risk of recurrent MI.
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Affiliation(s)
- Olurinde A Oni
- Division of Cardiovascular Research, Kansas City VA Medical Center, Kansas City, Missouri
| | | | - Mohammad-Ali Jazayeri
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Rishi Sharma
- Division of Cardiovascular Research, Kansas City VA Medical Center, Kansas City, Missouri
| | - Mukut Sharma
- Division of Cardiovascular Research, Kansas City VA Medical Center, Kansas City, Missouri
| | - Reza Masoomi
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Ram Sharma
- Division of Cardiovascular Research, Kansas City VA Medical Center, Kansas City, Missouri
| | - Kamal Gupta
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Rajat S Barua
- Division of Cardiovascular Research, Kansas City VA Medical Center, Kansas City, Missouri; Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas; Division of Cardiovascular Medicine, Kansas City VA Medical Center, Kansas City, Missouri.
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Ramachandran S, Hackett GI, Strange RC. Sex Hormone Binding Globulin: A Review of its Interactions With Testosterone and Age, and its Impact on Mortality in Men With Type 2 Diabetes. Sex Med Rev 2019; 7:669-678. [DOI: 10.1016/j.sxmr.2019.06.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/04/2019] [Accepted: 06/11/2019] [Indexed: 12/12/2022]
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Loo SY, Azoulay L, Nie R, Dell'Aniello S, Yu OHY, Renoux C. Cardiovascular and Cerebrovascular Safety of Testosterone Replacement Therapy Among Aging Men with Low Testosterone Levels: A Cohort Study. Am J Med 2019; 132:1069-1077.e4. [PMID: 30953635 DOI: 10.1016/j.amjmed.2019.03.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/01/2019] [Accepted: 03/01/2019] [Indexed: 01/10/2023]
Abstract
PURPOSE We assessed the risk of ischemic stroke, transient ischemic attack, and myocardial infarction associated with testosterone replacement therapy (TRT) among aging men with low testosterone levels. METHODS Using the UK Clinical Practice Research Datalink, we formed a cohort of men aged 45 years or older with low testosterone levels and no evidence of hypogonadotropic or testicular disease, between 1995 and 2017. Hazard ratios (HRs) and 95% confidence intervals (CIs) of a composite of ischemic stroke/transient ischemic attack and myocardial infarction were estimated using time-dependent Cox proportional hazards models, comparing current use of TRT with nonuse. RESULTS The cohort included 15,401 men. During 71,541 person-years of follow-up, 850 patients experienced an ischemic stroke/transient ischemic attack/myocardial infarction (crude incidence rate 1.19 [95% confidence interval (CI), 1.11-1.27] per 100 persons per year). Compared with nonuse, current use of TRT was associated with an increased risk of the composite outcome (HR 1.21; 95% CI, 1.00-1.46). This risk was highest in the first 6 months to 2 years of continuous TRT use (HR 1.35; 95% CI, 1.01-1.79), as well as among men aged 45-59 years (HR 1.44; 95% CI, 1.07-1.92). CONCLUSIONS TRT may increase the risk of cardiovascular events in aging men with low testosterone levels, particularly in the first 2 years of use. In the absence of identifiable causes of hypogonadism, TRT should be initiated with caution among aging men with low testosterone levels.
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Affiliation(s)
- Simone Y Loo
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Laurent Azoulay
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Québec, Canada; Gerald Bronfman Department of Oncology, McGill University, Montreal, Québec, Canada
| | - Rui Nie
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Sophie Dell'Aniello
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada
| | - Oriana Hoi Yun Yu
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada; Division of Endocrinology, Jewish General Hospital, Montreal, Québec, Canada
| | - Christel Renoux
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Québec, Canada; Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Québec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada.
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23
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Piccirillo G, Moscucci F, Pofi R, D'Alessandro G, Minnetti M, Isidori AM, Francomano D, Lenzi A, Puddu PE, Alexandre J, Magrì D, Aversa A. Changes in left ventricular repolarization after short-term testosterone replacement therapy in hypogonadal males. J Endocrinol Invest 2019; 42:1051-1065. [PMID: 30838540 PMCID: PMC6692303 DOI: 10.1007/s40618-019-01026-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/14/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Evidences suggest that androgen deficiency is associated with sudden cardiac death (SCD). Our purpose was to analyse some electrocardiographic (ECG) markers of repolarization phase in hypogonadal patients either at baseline or after testosterone replacement therapy (TRT). PATIENTS AND METHODS Baseline and after 6 months of testosterone replacement therapy, 14 hypogonadal patients and 10 age-matched controls underwent a short-term ECG recordings at rest and immediately after a maximal exercise test. The following ECG parameters have been collected: QTe (the interval between the q wave the end of T wave), QTp (the interval between the q wave and the peak of T wave), and Te (the interval between the peak and the end of T wave). RESULTS At baseline, in the hypogonadal patients, corrected QTe and QTp values were longer at rest than in the controls at rest (p < 0.05), whereas, during the recovery phase, only the QTp remained significantly longer (p < 0.05). After TRT, hypogonadal patients showed an improvement only in Te (p < 0.05). Conversely, any difference between hypogonadal patients and control subjects was found with respect to the markers of temporal dispersion of repolarization phases, except for a worse QTp → Te coherence (p = 0.001) obtained during the recovery phase. CONCLUSIONS In conclusion, at rest, hypogonadal patients suffer from a stable increase in the myocardial repolarization phase without an increase in its temporal dispersion and, hence, the SCD risk seems to be low.
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Affiliation(s)
- G Piccirillo
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, "La Sapienza" University of Rome, Viale del Policlinico, 00185, Rome, Italy
| | - F Moscucci
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, "La Sapienza" University of Rome, Viale del Policlinico, 00185, Rome, Italy.
| | - R Pofi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G D'Alessandro
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, "La Sapienza" University of Rome, Viale del Policlinico, 00185, Rome, Italy
| | - M Minnetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D Francomano
- Division of Internal Medicine and Endocrinology, Madonna delle Grazie Hospital, Velletri, Rome, Italy
| | - A Lenzi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - P E Puddu
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesiologiche e Geriatriche, Policlinico Umberto I, "La Sapienza" University of Rome, Viale del Policlinico, 00185, Rome, Italy
- EA 4650, Signalisation, électrophysiologie et imagerie des lésions d'ischémie reperfusion myocardique, Université de Caen, Normandie, France
| | - J Alexandre
- EA 4650, Signalisation, électrophysiologie et imagerie des lésions d'ischémie reperfusion myocardique, Université de Caen, Normandie, France
- Department of Pharmacology, CHU Caen, Caen, France
| | - D Magrì
- Dipartimento di Medicina Clinica e Molecolare, S. Andrea Hospital, "Sapienza" University of Rome, Rome, Italy
| | - A Aversa
- Department of Experimental and Clinical Medicine, University of Catanzaro « Magna Grecia », Catanzaro, Italy
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Corona G, Rastrelli G, Guaraldi F, Tortorici G, Reismann Y, Sforza A, Maggi M. An update on heart disease risk associated with testosterone boosting medications. Expert Opin Drug Saf 2019; 18:321-332. [PMID: 30998433 DOI: 10.1080/14740338.2019.1607290] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION The cardiovascular (CV) safety of testosterone replacement therapy (TRT) remains a crucial issue in the management of subjects with late-onset hypogonadism. The authors systematically reviewed and discussed the available evidence focusing our analysis on heart-related issues. AREAS COVERED All the available data from prospective observational studies evaluating the role endogenous T levels on the risk of acute myocardial infarction (AMI) were collected and analyzed. In addition, the impact of TRT on heart-related diseases, as derived from pharmaco-epidemiological studies as well as from randomized placebo-controlled trials (RCTs), was also investigated. EXPERT OPINION Available evidence indicates that endogenous low T represents a risk factor of AMI incidence and its related mortality. TRT in hypogonadal patients is able to improve angina symptoms in subjects with ischemic heart diseases and exercise ability in patients with heart failure (HF). In addition, when prescribed according to the recommended dosage, TRT does not increase the risk of heart-related events.
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Affiliation(s)
- G Corona
- a Endocrinology Unit, Medical Department, Azienda-Usl Bologna , Maggiore-Bellaria Hospital , Bologna , Italy
| | - G Rastrelli
- b Andrology, Female Endocrinology and Gender Incongruence Unit, Department of Experimental, Clinical and Biomedical Sciences , University of Florence , Florence , Italy
| | - F Guaraldi
- a Endocrinology Unit, Medical Department, Azienda-Usl Bologna , Maggiore-Bellaria Hospital , Bologna , Italy.,c Pituitary Unit , IRCCS Institute of Neurological Science of Bologna , Bologna , Italy
| | - G Tortorici
- d Cardiology Unit, Medical Department, Azienda-Usl Bologna , Maggiore Hospital , Bologna , Italy
| | - Y Reismann
- e Department of Urology , Amstelland Hospital , Amsterdam , The Netherlands
| | - A Sforza
- a Endocrinology Unit, Medical Department, Azienda-Usl Bologna , Maggiore-Bellaria Hospital , Bologna , Italy
| | - M Maggi
- b Andrology, Female Endocrinology and Gender Incongruence Unit, Department of Experimental, Clinical and Biomedical Sciences , University of Florence , Florence , Italy
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Nightingale TE, Moore P, Harman J, Khalil R, Gill RS, Castillo T, Adler RA, Gorgey AS. Body composition changes with testosterone replacement therapy following spinal cord injury and aging: A mini review. J Spinal Cord Med 2018; 41:624-636. [PMID: 28770686 PMCID: PMC6217462 DOI: 10.1080/10790268.2017.1357917] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Context Hypogonadism is a male clinical condition in which the body does not produce enough testosterone. Testosterone plays a key role in maintaining body composition, bone mineral density, sexual function, mood, erythropoiesis, cognition and quality of life. Hypogonadism can occur due to several underlying pathologies during aging and in men with physical disabilities, such as spinal cord injury (SCI). This condition is often under diagnosed and as a result, symptoms undertreated. Methods In this mini-review, we propose that testosterone replacement therapy (TRT) may be a viable strategy to improve lean body mass (LBM) and fat mass (FM) in men with SCI. Evidence Synthesis Supplementing the limited data from SCI cohorts with consistent findings from studies in non-disabled aging men, we present evidence that, relative to placebo, transdermal TRT can increase LBM and reduce FM over 3-36 months. The impact of TRT on bone mineral density and metabolism is also discussed, with particular relevance for persons with SCI. Moreover, the risks of TRT remain controversial and pertinent safety considerations related to transdermal administration are outlined. Conclusion Further research is necessary to help develop clinical guidelines for the specific dose and duration of TRT in persons with SCI. Therefore, we call for more high-quality randomized controlled trials to examine the efficacy and safety of TRT in this population, which experiences an increased risk of cardiometabolic diseases as a result of deleterious body composition changes after injury.
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Affiliation(s)
- Tom E. Nightingale
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Pamela Moore
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Joshua Harman
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Refka Khalil
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | - Ranjodh S. Gill
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Teodoro Castillo
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Robert A. Adler
- Endocrinology Service, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Endocrine Division, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA,Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA,Correspondence to: Ashraf S. Gorgey, Department of Veterans Affairs, Hunter Holmes McGuire Medical Center, Spinal Cord Injury & Disorders Service, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA.
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Li H, Mitchell L, Zhang X, Heiselman D, Motsko S. Testosterone Therapy and Risk of Acute Myocardial Infarction in Hypogonadal Men: An Administrative Health Care Claims Study. J Sex Med 2018; 14:1307-1317. [PMID: 29110802 DOI: 10.1016/j.jsxm.2017.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 09/12/2017] [Accepted: 09/16/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND There are some ongoing debates on the potential link between testosterone therapy (TT) and risk of acute myocardial infarction (MI). AIM To investigate the association between acute MI and TT use compared with non-use in men having documented hypogonadism (diagnostic International Classification of Diseases, Ninth Revision codes 257.2, 257.8, 257.9, 758.7) in patient claims records. METHODS This retrospective cohort study used a real-world US-based administrative health care claims database (MarketScan 2004-2013; Truven Health Analytics, Ann Arbor, MI, USA) to compare MI rates between TT-treated men and a cohort of untreated hypogonadal men matched by a calendar time-specific propensity score. Subgroup analyses were performed by route of administration, age, and prior cardiovascular disease (CVD). OUTCOMES Incidence rates of MI (per 1,000 person-years) and hazard ratio. RESULTS After 1:1 calendar time-specific propensity score matching, 207,176 TT-treated men and 207,176 untreated hypogonadal men were included in the analysis (mean age = 51.8 years). Incidence rates of MI were 4.20 (95% CI = 3.87-4.52) in the TT-treated cohort and 4.67 (95% CI = 4.43-4.90) in the untreated hypogonadal cohort. Cox regression model showed no significant association between TT use and MI when comparing TT-treated with untreated hypogonadal men overall (hazard ratio = 0.99, 95% CI = 0.89-1.09), by age, or by prior CVD. A significant association was observed when comparing a subgroup of injectable (short- and long-acting combined) TT users with untreated hypogonadal men (hazard ratio = 1.55, 95% CI = 1.24-1.93). CLINICAL IMPLICATION In this study, there was no association between TT (overall) and risk of acute MI. STRENGTHS AND LIMITATIONS Strengths included the use of a comprehensive real-world database, sophisticated matching based on calendar blocks of 6 months to decrease potential bias in this observational study, carefully chosen index dates for the untreated cohort to avoid immortal time bias, and implemented sensitivity analysis to further investigate the findings (stratification by administration route, age, and prior CVD). Key limitations included no information about adherence, hypogonadism condition based solely on diagnosis (no information on clinical symptoms or testosterone levels), lack of information on disease severity, inability to capture diagnoses, medical procedures, and medicine dispensing if corresponding billing codes were not generated and findings could contain biases or fail to generalize well to other populations. CONCLUSION This large, retrospective, real-world observational study showed no significant association between TT use and acute MI when comparing TT-treated with untreated hypogonadal men overall, by age, or by prior CVD; the suggested association between injectable TT and acute MI deserves further investigation. Li H, Mitchell L, Zhang X, et al. Testosterone Therapy and Risk of Acute Myocardial Infarction in Hypogonadal Men: An Administrative Health Care Claims Study. J Sex Med 2017;14:1307-1317.
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Affiliation(s)
- Hu Li
- Eli Lilly and Company, Indianapolis, IN, USA.
| | - Lucy Mitchell
- Eli Lilly and Company Limited, Erlwood, Windlesham, Surrey, UK
| | - Xiang Zhang
- Eli Lilly and Company, Indianapolis, IN, USA
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Clavell-Hernández J, Wang R. Emerging Evidences in the Long Standing Controversy Regarding Testosterone Replacement Therapy and Cardiovascular Events. World J Mens Health 2018; 36:92-102. [PMID: 29706034 PMCID: PMC5924961 DOI: 10.5534/wjmh.17050] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 10/19/2017] [Indexed: 02/02/2023] Open
Abstract
The increasing rate of late-onset hypogonadism has led to an exceptional growth in the use of testosterone therapy (TTh). Even though TTh has been used for more than 70 years, there has been an emerging controversy in the past several years regarding its safety due to a suggested increased risk of cardiovascular (CV) disease among its users. Given the growing prevalence of testosterone deficiency in our population and the increased use of TTh, the goal of this review is to present the history and emerging evidence in regards to this controversy. CV safety concerns are mostly based on a few studies and trials that have been noted to have multiple flaws and limitations. However, the most recent data has found no association between TTh and the development of CV disease. Nevertheless, until this controversy is clarified with larger clinical trials, health-care professionals should continue to inform their patients about the possible CV risk when prescribing TTh products to patients.
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Affiliation(s)
- Jonathan Clavell-Hernández
- Division of Urology, University of Texas Health Science Center, McGovern Medical School at Houston, Houston, TX, USA
- Department of Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Run Wang
- Division of Urology, University of Texas Health Science Center, McGovern Medical School at Houston, Houston, TX, USA
- Department of Surgery, University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
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[Androgens and cardiovascular risk: A series of case report in the French and Canadian pharmacovigilance databases]. Prog Urol 2018; 28:315-321. [PMID: 29650456 DOI: 10.1016/j.purol.2018.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 11/12/2017] [Accepted: 03/16/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Age-related androgenic deficiency (DALA) is a pathology that is increasingly cited in recent publications. The cardiovascular risk of testosterone is debated: present for the FDA, absent for the European Medicines Agency in 2015. Our objective was to analyze the association between androgens and vascular pathologies in adverse reactions reported in pharmacovigilance databases. MATERIAL AND METHOD We conducted a retrospective case series study of the French and Canadian pharmacovigilance databases for the period 2005-2015. Cases were defined as the association of the occurrence of a cardiovascular event (myocardial infarction or stroke) and the presence of testosterone in the treatment of patients. RESULTS Of the 10 years analyzed, 12 French cases and 6 Canadian cases (representing 13 MIs and 5 strokes) were recorded in men aged 55 years on average. All were doubtful: differential diagnoses were possible (2.4 confounding conditions on average per patient) and overall cardiovascular risk was high for the majority of cases. CONCLUSION Our study shows a very low report of cardiovascular effects under testosterone, all doubtful. Pending further studies, it seems reasonable to consider the cardiovascular risk of patients who are candidates for hormone therapy for age-related androgen deficiency. LEVEL OF EVIDENCE 3.
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Chrysant SG, Chrysant GS. Cardiovascular benefits and risks of testosterone replacement therapy in older men with low testosterone. Hosp Pract (1995) 2018; 46:47-55. [PMID: 29478348 DOI: 10.1080/21548331.2018.1445405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Many studies have shown that low testosterone (T) levels have been associated with increased risk for cardiovascular (CV) events, type 2 diabetes mellitus (T2DM), and strokes. In contrast, many other studies have demonstrated that normal T levels or the normalization of low T levels with testosterone replacement therapy (TRT) is associated with decreased incidence of CV events, T2DM, and strokes, besides improving sexual function and the quality of life. However, recent studies have indicated that TRT could lead to increased incidence of CV events and strokes. These latter studies have created a great controversy among physicians regarding these findings, who question the validity of their results. In order to get a better perspective on the current status of TRT in hypogonadal men, a focused Medline and EMBASE search of the English language literature was conducted between 2010 and 2017 using the terms hypogonadism, low Testosterone, cardiovascular disease, testosterone replacement therapy, benefits, risks, older men, mechanism of action, and 58 papers with pertinent information were selected and 48 papers were rejected. The selected papers will be discussed in this review. In conclusion, based on the current status of TRT, the majority of studies indicate that TRT is safe and is associated with prevention of CVD and strokes in hypogonadal men. However, the evidence is not uniform and the therefore, decision to administer TRT should be discussed with the patient till more definitive information becomes available.
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Affiliation(s)
- Steven G Chrysant
- a Department of Cardiology , University of Oklahoma Health Sciences Center , Oklahoma City , OK , USA
| | - George S Chrysant
- b Department of Cardiology , INTEGRIS Baptist Medical Center , Oklahoma City , OK , USA
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Abstract
Hypogonadism is a common condition defined by the presence of low serum testosterone levels and hypogonadal symptoms, and most commonly treated using testosterone therapy (TTh). The accuracy of diagnosis and appropriateness of treatment, along with proper follow-up, are increasingly important given the large increase in testosterone prescriptions and the recent concern for cardiovascular (CV) risk associated with TTh. In March of 2015, the US Food and Drug Administration required that testosterone product labels disclose a potential CV risk, despite the evidence base for this association being weak and inconclusive. However, TTh may improve CV outcomes rather than increase risks.
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Affiliation(s)
- John T Sigalos
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Alexander W Pastuszak
- Center for Reproductive Medicine, Baylor College of Medicine, 1 Baylor Plaza, Room N730 Houston, TX 77030, USA; Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA
| | - Mohit Khera
- Scott Department of Urology, Baylor College of Medicine, 7200 Cambridge Street, Houston, TX 77030, USA.
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Wroclawski ML, Heldwein FL. Do we have enough evidences that make you safe to treat a man with hypogonadism one year after a radical prostatectomy for prostate cancer? | Opinion: Not Yet. Int Braz J Urol 2018; 44:8-13. [PMID: 29424507 PMCID: PMC5815527 DOI: 10.1590/s1677-5538.ibju.2018.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Marcelo Langer Wroclawski
- Hospital Israelita Albert Einstein, São Paulo, SP, Brasil
- Faculdade de Medicina do ABC, Santo André, SP, Brasil
| | - Flavio Lobo Heldwein
- Universidade do Sul de Santa Catarina, SC, Brasil
- Universidade Federal de Santa Catarina, SC, Brasil
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32
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Elagizi A, Köhler TS, Lavie CJ. Testosterone and Cardiovascular Health. Mayo Clin Proc 2018; 93:83-100. [PMID: 29275030 DOI: 10.1016/j.mayocp.2017.11.006] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/07/2017] [Accepted: 11/13/2017] [Indexed: 12/29/2022]
Abstract
There is an ongoing debate in the medical community regarding the effects of testosterone on cardiovascular (CV) health. For decades, there has been conflicting evidence regarding the association of endogenous testosterone levels and CV disease (CVD) events that has resulted in much debate and confusion among health care providers and patients alike. Testosterone therapy has become increasingly widespread, and after the emergence of studies that reported increased CVD events in patients receiving testosterone therapy, the US Food and Drug Administration (FDA) released a warning statement about testosterone and its potential risk regarding CV health. Some of these studies were later found to be critically flawed, and some experts, including the American Association of Clinical Endocrinologists and an expert panel regarding testosterone deficiency and its treatment, reported that some of the FDA statements regarding testosterone therapy were lacking scientific evidence. This article summarizes the current evidence regarding the relationship between testosterone (endogenous and supplemental) and CV health. A literature review was conducted via search using PubMed and specific journal databases, including the New England Journal of Medicine and the Journal of the American College of Cardiology. Key search terms included testosterone and cardiovascular health, coronary artery disease, heart failure, androgen deprivation therapy, intima-media thickness, and adrenal androgens. Initial study selection was limited to publications within the past 10 years (January 1, 2007, through December 31, 2016); however, key publications outside of this time frame were selected if they provided important quantitative data or historical perspectives for the review of this topic. The search was further supplemented by reviewing references in selected articles.
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Affiliation(s)
- Andrew Elagizi
- Department of Internal Medicine, Leonard J. Chabert Medical Center, Houma, LA
| | - Tobias S Köhler
- Department of Urology, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA.
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Testosterone and Cardiovascular Diseases: Causes or Consequences: The Lesson from the Last 5 Years. CURRENT SEXUAL HEALTH REPORTS 2017. [DOI: 10.1007/s11930-017-0132-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Loo SY, Chen BY, Yu OHY, Azoulay L, Renoux C. Testosterone replacement therapy and the risk of stroke in men: A systematic review. Maturitas 2017; 106:31-37. [PMID: 29150164 DOI: 10.1016/j.maturitas.2017.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 10/18/2022]
Abstract
In recent years, questions have been raised regarding the cardiovascular safety of testosterone replacement therapy (TRT). The objective of this study was to systematically review the available evidence on TRT safety in men, specifically with respect to the risk of stroke. We identified publications from MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials up to May 2017. Articles eligible for review included observational studies evaluating TRT and the risk of stroke among men aged 18 or older. Randomized controlled trials (RCTs) comparing testosterone to placebo in men were also eligible, provided stroke was identified as an adverse event. Among seven cohort studies of hypogonadal men, one study reported that TRT was associated with a significant decrease in the risk of ischemic stroke (hazard ratio (HR) 0.64; 95% confidence interval (CI) 0.52-0.80). Another reported a similar decrease in risk (HR 0.64; 95% CI 0.43-0.96) among treated men who achieved normalized levels of testosterone. Limitations in study design, including immortal time bias and residual confounding, may have influenced both of these results. The remaining observational studies did not report measures of association to estimate the independent risk of stroke associated with TRT. Among eight RCTs, a low frequency of stroke events (<5) was observed across both testosterone and control groups, thus precluding any definitive conclusions. Based on these findings, the association between TRT and the risk of stroke in men remains unclear, and further large and methodologically robust studies are needed to establish this relationship.
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Affiliation(s)
- Simone Y Loo
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Bing Yu Chen
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Oriana Hoi Yun Yu
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Division of Endocrinology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Christel Renoux
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada.
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Quality of Life and Sexual Function Benefits of Long-Term Testosterone Treatment: Longitudinal Results From the Registry of Hypogonadism in Men (RHYME). J Sex Med 2017; 14:1104-1115. [PMID: 28781213 DOI: 10.1016/j.jsxm.2017.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 06/27/2017] [Accepted: 07/01/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The benefits and risks of long-term testosterone administration have been a topic of much scientific and regulatory interest in recent years. AIM To assess long-term quality of life (QOL) and sexual function benefits of testosterone replacement therapy (TRT) prospectively in a diverse, multinational cohort of men with hypogonadism. METHODS A multinational patient registry was used to assess long-term changes associated with TRT in middle-age and older men with hypogonadism. Comprehensive evaluations were conducted at 6, 12, 24, and 36 months after enrollment into the registry. OUTCOMES QOL and sexual function were evaluated by validated measures, including the Aging Males' Symptom (AMS) Scale and the International Index of Erectile Function (IIEF). RESULTS A total of 999 previously untreated men with hypogonadism were enrolled at 25 European centers, 750 of whom received TRT at at least one visit during the period of observation. Patients on TRT reported rapid and sustained improvements in QOL, with fewer sexual, psychological, and somatic symptoms. Modest improvements in QOL and sexual function, including erectile function, also were noted in RHYME patients not on TRT, although treated patients showed consistently greater benefit over time in all symptom domains compared with untreated patients. AMS total scores for patients on TRT were 32.8 (95% confidence interval = 31.3-34.4) compared with 36.6 (95% confidence interval = 34.8-38.5) for untreated patients (P < .001). Small but significant improvements in IIEF scores over time also were noted with TRT. Approximately 25% of treated and untreated men also used phosphodiesterase type 5 inhibitors, with notable differences in the frequency of phosphodiesterase type 5 inhibitor prescription use according to physician specialty and geographic site location. CLINICAL IMPLICATIONS TRT-related benefits in QOL and sexual function are well maintained for up to 36 months after initiation of treatment. STRENGTHS AND LIMITATIONS The major strengths are the large, diverse patient population being treated in multidisciplinary clinical settings. The major limitation is the frequency of switching from one formulation to another. CONCLUSION Overall, we confirmed the broad and sustained benefits of TRT across major QOL dimensions, including sexual, somatic, and psychological health, which were sustained over 36 months in our treatment cohort. Rosen RC, Wu F, Behre H, et al. Quality of Life and Sexual Function Benefits Effects of Long-Term Testosterone Treatment: Longitudinal Results From the Registry of Hypogonadism in Men (RHYME). J Sex Med 2017;14:1104-1115.
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36
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Corona G, Dicuio M, Rastrelli G, Maseroli E, Lotti F, Sforza A, Maggi M. Testosterone treatment and cardiovascular and venous thromboembolism risk: what is 'new'? J Investig Med 2017; 65:964-973. [PMID: 28495861 DOI: 10.1136/jim-2017-000411] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2017] [Indexed: 12/21/2022]
Abstract
In men, testosterone (T) production declines as a function of ageing. Late-onset hypogonadism (LOH) is the most commonly used term to indicate this age-related condition. In LOH, the relative clinical significance and the potential benefit of testosterone treatment (TTh) are still the subject of strong criticisms in the scientific community. The debate is further complicated by the recent position statement of the US Food and Drug Administration (FDA) emphasizing that, in LOH, the benefits and safety of TTh have not been fully established. Hence, the FDA required a labeling change to inform patients about a possible increased cardiovascular (CV) risk of TTh. Similar considerations were previously released by the FDA and by Health Canada concerning a TTh-related venous thromboembolism (VTE) risk. In this review, we will summarize the available evidence concerning a possible link among TTh and CV and VTE risks. For this purpose, data derived from epidemiological studies analyzing relationships between the aforementioned risks and endogenous T levels will be analyzed. In addition, evidence deriving from interventional studies including pharmacoepidemiological and placebo-controlled randomized controlled trials (RCTs) will be examined. Our analysis shows that available data do not support an increased CV risk related to TTh. Similar considerations can be drawn for the relationship between TTh and VTE. The previously reported cases of TTh-related VTE were frequently related to a previously undiagnosed thrombophilia-hypofibrinolysis status. Hence, an anamnestic screening for thrombophilia before starting TTh is recommended, just as it is for the use of oral contraceptives.
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Affiliation(s)
- G Corona
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Azienda-Usl Bologna, Bologna, Italy
| | - M Dicuio
- Urology Unit, Maggiore Hospital, Bologna, Italy.,Department of Urology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - G Rastrelli
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - E Maseroli
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - F Lotti
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - A Sforza
- Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Azienda-Usl Bologna, Bologna, Italy
| | - M Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy
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Igel LI, Kumar RB, Saunders KH, Aronne LJ. Practical Use of Pharmacotherapy for Obesity. Gastroenterology 2017; 152:1765-1779. [PMID: 28192104 DOI: 10.1053/j.gastro.2016.12.049] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 01/07/2023]
Abstract
Obesity management requires a multidisciplinary approach, as there are many factors that contribute to the development of obesity, as well as the preservation of excess weight once it has been gained. Diet, exercise, and behavior modification are key components of treatment. In addition to lifestyle changes, weight gain secondary to medications is an important modifiable risk factor. Even after appropriate lifestyle modification, and medication adjustments (where possible) to avoid agents that can contribute to weight gain, many patients are still unable to achieve clinically meaningful weight loss. Pharmacotherapy for obesity management can fill an important role for these patients. This article will review medications that can lead to weight gain and potential alternatives, currently approved anti-obesity medications and best practices to individualize the selection process, and the use of testosterone in men with hypogonadism and obesity.
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Affiliation(s)
- Leon I Igel
- Comprehensive Weight Control Center, Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medical College, New York, New York.
| | - Rekha B Kumar
- Comprehensive Weight Control Center, Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medical College, New York, New York
| | - Katherine H Saunders
- Comprehensive Weight Control Center, Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medical College, New York, New York
| | - Louis J Aronne
- Comprehensive Weight Control Center, Division of Endocrinology, Diabetes and Metabolism, Weill Cornell Medical College, New York, New York
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Corona G, Sforza A, Maggi M. Testosterone Replacement Therapy: Long-Term Safety and Efficacy. World J Mens Health 2017; 35:65-76. [PMID: 28497912 PMCID: PMC5583373 DOI: 10.5534/wjmh.2017.35.2.65] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 04/10/2017] [Indexed: 12/12/2022] Open
Abstract
Recent position statements and guidelines have raised the distinction between a true and false, age-related hypogonadism (HG) or late-onset hypogonadism (LOH). The former is the consequence of congenital or acquired “organic” damage of the brain centers or of the testis. The latter is mainly secondary to age-related comorbidities and does not require testosterone (T) therapy (TTh). In addition, concerns related to cardiovascular (CV) safety have further increased the scepticism related to TTh. In this paper, we reviewed the available evidence supporting the efficacy of TTh in non-organic HG and its long term safety. A large amount of evidence has documented that sexual symptoms are the most specific correlates of T deficiency. TTh is able to improve all aspects of sexual function independent of the pathogenetic origin of the disease supporting the scientific demonstration that LOH does exist according to an “ex-juvantibus” criterion. Although the presence of metabolic derangements could mitigate the efficacy of TTh on erectile dysfunction, the positive effect of TTh on body composition and insulin sensitivity might counterbalance the lower efficacy. CV safety concerns related to TTh are essentially based on a limited number of observational and randomized controlled trials which present important methodological flaws. When HG is properly diagnosed and TTh correctly performed no CV and prostate risk have been documented.
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Affiliation(s)
- Giovanni Corona
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Alessandra Sforza
- Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy
| | - Mario Maggi
- Sexual Medicine and Andrology Unit, Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Italy.
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Foresta C, Ferlin A, Lenzi A, Montorsi P. The great opportunity of the andrological patient: cardiovascular and metabolic risk assessment and prevention. Andrology 2017; 5:408-413. [DOI: 10.1111/andr.12342] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/13/2017] [Accepted: 01/25/2017] [Indexed: 12/15/2022]
Affiliation(s)
- C. Foresta
- Department of Medicine; Unit of Andrology and Reproductive Medicine; University of Padova; Padova Italy
| | - A. Ferlin
- Department of Medicine; Unit of Andrology and Reproductive Medicine; University of Padova; Padova Italy
| | - A. Lenzi
- Department of Experimental Medicine; Section of Medical Pathophysiology, Food and Science and Endocrinology; Sapienza University of Rome; Rome Italy
| | - P. Montorsi
- Department of Clinical Sciences and Community Health; Centro Cardiologico Monzino; IRCCS; University of Milan; Milan Italy
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Negative Impact of Testosterone Deficiency and 5α-Reductase Inhibitors Therapy on Metabolic and Sexual Function in Men. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1043:473-526. [DOI: 10.1007/978-3-319-70178-3_22] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
Cardiovascular disease (CVD) is the most prevalent non-communicable cause of death worldwide. Testosterone is a sex hormone that is predominant in males but also occurs in lower concentrations in females. It has effects directly on the blood vessels of the cardiovascular system and on the heart, as well as effects on risk factors for CVD. Serum testosterone concentrations are known to decrease with age and reduced testosterone levels are linked to premature coronary artery disease, unfavourable effects on CVD risk factors and increased risk of cardiovascular mortality independent of age. A significant number of men with heart failure demonstrate reduced serum testosterone concentrations and there is early evidence suggesting that low testosterone levels affect cardiac repolarisation. Any association between endogenous testosterone concentrations and CVD in women has yet to be established. Testosterone replacement is used to treat men with hypogonadism but also has cardiovascular effects. This review will present the current evidence, expert opinion and controversies around the role of testosterone in the pathophysiology of CVD and surrounding the use of testosterone treatment and its effects on the cardiovascular system and CVD.
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Affiliation(s)
- Carolyn M Webb
- Vascular Biology, National Heart and Lung Institute, Imperial College London and Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust London, UK
| | - Peter Collins
- Vascular Biology, National Heart and Lung Institute, Imperial College London and Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust London, UK
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