Study protocol to investigate the effects of testosterone therapy as an adjunct to exercise rehabilitation in hypogonadal males with chronic heart failure

Will testosterone replacement therapy become a new treatment of chronic heart failure? A review based on 8 clinical trials

BACKGROUND

According to the present evidences suggesting association between low testosterone level and prediction of reduced exercise capacity as well as poor clinical outcome in patients with heart failure, we sought to determine if testosterone replacement therapy (TRT) improves clinical and cardiovascular conditions as well as quality of life status in patients with stable chronic heart failure (CHF).

METHODS

We carried out a review based on 8 published clinical trials to determine whether TRT will benefit patients with CHF. Information of exercise capacity, hemodynamic parameters, electrocardiogram indicators, muscle strength, echocardiography guidelines and laboratory indexes were collected to assess clinical outcomes.

RESULTS

We found that TRT could improve significantly exercise capacity, muscle strength and electrocardiogram indicators but no significant changes in ejection fraction (EF), systolic blood pressure (SBP), diastolic blood pressure (DBP), N-terminal pro-brain natriuretic peptide (NT-proBNP), tumor necrosis factor-α (TNF-α), high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL-6).

CONCLUSIONS

High-quality studies are required to better understand the clinical effects of testosterone.

Measurement properties of the incremental shuttle walk test. a systematic review

Background: The incremental shuttle walk test (ISWT) was developed > 20 years ago and has been used to assess peak exercise capacity in a variety of chronic diseases. The aim of this systematic review is to describe the measurement properties of the ISWT in a clinical population.Methods: Of 800 articles identified by electronic and hand searches, 35 were included. Twenty-one articles included data on the validity of the ISWT, 18 on the reliability, four on the responsiveness,and four on the interpretability.Results: Most of the studies were conducted in patients with COPD (n = 13) or cardiac disease(n = 8). For criterion validity, comparisons between distance covered during the ISWT and peak oxygen consumption reported correlations ranging from 0.67 to 0.95 ( P <.01). Intraclass correlation coefficients for test-retest reliability ranged from 0.76 to 0.99. The ISWT was shown to be responsive to pulmonary rehabilitation and bronchodilator administration. The minimal clinically important difference (MCID) in patients with COPD was 48 m. Predictive equations for the distance in the ISWT are available for healthy individuals.Conclusions: The ISWT can be considered a valid and reliable test to assess maximal exercise capacity in individuals with chronic respiratory diseases. The ISWT has been shown to be responsive to pulmonary rehabilitation and bronchodilator use in individuals with COPD, cystic fibrosis,and asthma. Further studies examining responsiveness and the MCID of the ISWT in patients with conditions other than lung diseases are required for the interpretation of interventions in other populations.

Risks of testosterone replacement therapy in men

Testosterone replacement therapy (TRT) is a widely used treatment for men with symptomatic hypogonadism. The benefits seen with TRT, such as increased libido and energy level, beneficial effects on bone density, strength and muscle as well as cardioprotective effects, have been well-documented. TRT is contraindicated in men with untreated prostate and breast cancer. Men on TRT should be monitored for side-effects such as polycythemia, peripheral edema, cardiac and hepatic dysfunction.

A theory-based exercise intervention in patients with heart failure: A protocol for randomized, controlled trial

BACKGROUND

Regular exercise has been associated with improved quality of life (QoL) in patients with heart failure (HF). However, less is known on the theoretical framework, depicting how educational intervention on psychological, social, and cognitive variables affects physical activity (PA). The purpose of this study is to assess the effectiveness of a social cognitive theory-based (SCT-based) exercise intervention in patients with HF.

MATERIALS AND METHODS

This is a randomized controlled trial, with measurements at baseline, immediately following the intervention, and at 1, 3, and 6 months follow-up. Sixty patients who are referred to the cardiac rehabilitation (CR) unit and meet the inclusion criteria will be randomly allocated to either an intervention group or a usual-care control group. Data will be collected using various methods (i.e., questionnaires, physical tests, paraclinical tests, patients' interviews, and focus groups). The patients in the intervention group will receive eight face-to-face counseling sessions, two focus groups, and six educational sessions over a 2-month period. The intervention will include watching videos, using book and pamphlets, and sending short massage services to the participants. The primary outcome measures are PA and QoL. The secondary outcome measures will be the components of SCT, heart rate and blood pressure at rest, body mass index, left ventricular ejection fraction, exercise capacity, and maximum heart rate.

CONCLUSION

The findings of this trial may assist with the development of a theoretical model for exercise intervention in CR. The intervention seems to be promising and has the potential to bridge the gap of the usually limited and incoherent provision of educational care in the CR setting.

Testosterone therapy during exercise rehabilitation in male patients with chronic heart failure who have low testosterone status: a double-blind randomized controlled feasibility study

BACKGROUND

This study assessed the feasibility of a 12-week program of exercise, with and without intramuscular testosterone supplementation, in male patients with chronic heart failure (CHF) and low testosterone status and collected preliminary data for key health outcomes.

METHODS

Male patients with CHF (n = 41, age 67.2 years, range 51-84 years) with mean ± SD testosterone levels of 10.7 ± 2.6 nmol/L (309 ± 76 ng/dL) were randomly allocated to exercise with testosterone or placebo groups. Feasibility was assessed in terms of recruitment, intervention compliance, and attrition. Outcomes included an incremental shuttle walk test, peak oxygen uptake, muscular strength, echocardiographic measures, N-terminal pro-brain natriuretic peptide, inflammatory markers, depression (Beck Depression Inventory), and health-related quality of life (Minnesota Living with Heart Failure Questionnaire and Medical Outcomes Study Short-Form).

RESULTS

Attrition was 30% but with 100% compliance to exercise and injections in patients who completed the study. Similar improvements in shuttle walk test (18% vs 19%), body mass (-1.3 kg vs -1.0 kg), and hand grip strength (2.1 kg vs 2.5 kg) from baseline were observed in both groups. The exercise with testosterone group showed improvements from baseline in peak oxygen uptake (P < .01), Beck Depression Inventory (P < .05), leg strength (P < .05), and several Medical Outcomes Study Short-Form quality of life domains (P < .05), which were generally not apparent in the exercise with placebo group. Echocardiographic measures, N-terminal pro-brain natriuretic peptide, and inflammatory markers were mostly unchanged.

CONCLUSIONS

This study shows for the first time that testosterone supplementation during a program of exercise rehabilitation is feasible and can positively impact on a range of key health outcomes in elderly male patients with CHF who have a low testosterone status.

Reposição hormonal e exercício físico no tratamento da insuficiência cardíaca: revisão sistemática

FUNDAMENTAÇÃO: A despeito do pleno uso da terapia farmacológica e não farmacológica, persistem as expressivas morbidade e mortalidade decorrentes da insuficiência cardíaca (IC). No contexto terapêutico é relevante a inibição das inadequadas adaptações neuro-hormonais e metabólicas, sendo bem conhecida a deficiência anabólica que se instala na IC. Mas somente recentemente surgiram alguns estudos sobre os benefícios que adviriam da terapia de reposição ou suplementação de testosterona (TRT). OBJETIVOS: Pesquisar estudos que abordem a TRT na insuficiência cardíaca (IC), em especial os desenvolvidos no cenário ideal de tratamento clínico, que inclui programa de exercício físico. MÉTODOS: Foram consultadas as bases de dados SciELO e PubMed, a base de dados Cochrane de Revisões Sistemáticas e o Registro de Ensaios Controlados da Colaboração Cochrane. RESULTADOS: Os poucos estudos sobre TRT em pacientes com IC evidenciaram melhora da função hemodinâmica, da resistência à insulina, da capacidade funcional e das respostas neuro-hormonal e neuromuscular, evidenciaram as controvérsias quanto à influência sobre o perfil inflamatório, e não constataram mudanças na função e na estrutura cardiovascular central. Entretanto, não foi encontrado nenhum estudo sobre TRT concomitante ao programa de exercícios físicos. CONCLUSÕES: O estágio atual de conhecimento, embora baseado em poucos estudos, permite considerar a TRT no tratamento de pacientes com IC. Não está bem definida a forma ideal da TRT, no que diz respeito à duração do tratamento, critérios de inclusão e exclusão etc. Existe uma grande lacuna na literatura, chamando atenção à inexistência de estudos sobre a TRT concomitante ao tratamento clínico pleno, que inclui um programa de exercícios físicos.

Testosterone and heart failure

PURPOSE OF REVIEW

Chronic heart failure (CHF) is a common condition with significant morbidity despite optimal medical therapy. Standard therapy involves inhibiting the maladaptive changes of metabolism and neuro-hormones that characterize the syndrome of CHF. Anabolic deficiency is a major component of the CHF syndrome and testosterone replacement therapy has been subject to recent trials.

RECENT FINDINGS

The recent literature shows that physiological testosterone replacement therapy leads to modest improvements in voluntary muscle strength, lean muscle mass, endurance and positive effects on neuro-muscular and baro-receptor reflexes. Long-term efficacy and safety remain unstudied at present.

SUMMARY

Testosterone replacement therapy appears to improve metabolism and endurance in patients with CHF; further trials will be necessary before widespread use. Physicians who regularly treat patients with CHF may consider testosterone therapy but it is likely that they will require the advice and support from endocrine specialists.

Association between Androgenic Hormone Levels and Left Ventricular Ejection Fraction

BACKGROUND

Androgens have been shown to have diverse effects on the cardiovascular system. The aim of this study was to compare androgenic hormone levels in patients with different left ventricular ejection fractions (EF).

METHODS

The study population consisted of 515 consecutive men who were referred for angiographic studies and whose results of echocardiography and coronary angiography were available. The patients were classified into four groups: EF < 35%, EF = 35-45%, EF = 45-54%, and EF ≥ 55% to evaluate the trends of baseline characteristics and serum androgens, including free testosterone (fT), total testosterone (tT), and dehydroepiandrosterone sulfate (DHEAS). To better elucidate the difference in the patients with severe heart failure, the patients were divided into two groups according to their EF level, and comparisons were repeated between those with EF < 35% and the ones with EF ≥ 35%.

RESULTS

There were statistically significant trends in some characteristics in the patients with different levels of EF. The subjects with higher EF levels were less likely to have diabetes (p value < 0.001), coronary artery lesion (p value < 0.001), or high levels of C-reactive protein (CRP) (p value < 0.001). As regards the patients with severe heart failure, our regression analysis revealed that the fT level was significantly lower in those with EF < 35% than in the ones with EF ≥ 35% (5.82 ± 2.73 pg/mL vs. 6.88 ± 3.34 pg/mL, p value < 0.05).

CONCLUSION

A significant association was found between the level of fT and EF < 35%. There is a need for further controlled prospective studies to delineate any possible causal relationship accurately.

Cardiovascular disease and androgens: a review

Globally, cardiovascular disease is the single largest cause of mortality. The differences in pattern of cardiovascular disease between the two genders have not been explained properly. The spotlight has largely been focused on estrogens but no conclusive evidence has proven its role in reducing the incidence of cardiovascular disease. Consequently, androgens have attracted significant interest in explaining the gender difference in cardiovascular disease. More studies in last two decades have increased our knowledge about the effects of androgens on cardiovascular disease progression. Evidence for age related fall in testosterone levels in males and increasing cardiovascular events with age had lead to the postulation of idea of 'andropause or male menopause'. Unfortunately, for the last few decades the androgens have been highlighted as agents of abuse among athletes all over the world. There have been multiple reports of their association with sudden cardiac death and adverse cardiovascular outcomes when abused. Contrastingly, there has been an increasing prescription use of testosterone supplementation in various conditions related to androgen deficiency state and for many other off-label indications. Human observational studies have mostly concluded that men with lower testosterone levels tend to have higher incidence of coronary artery disease. Emerging evidence supports that lower androgen levels predict poor cardiovascular risk profile. Role with supplementation of testosterone for cardiovascular disease is being studied in both primary and secondary prevention stages and its safety being evaluated. This is an appropriate time to review the role of androgens specifically from a cardiovascular standpoint.

Metabolic perturbation in chronic heart failure: time to redress the balance?

Evaluation of: Jankowska EA, Biel B, Majda J et al. : Anabolic deficiency in men with chronic heart failure; prevalence and detrimental impact on survival. Circulation 114, 1829-1837 (2006). The study examined the circulating levels of three anabolic hormones (testosterone, insulin-like growth factor-1 and dehydroepiandrosterone sulfate) in 208 men with stable chronic heart failure and 366 healthy controls. A high prevalence of anabolic hormone deficiency (89% deficient in one or more hormone) was found in heart failure patients. Hormone levels were weakly related to disease severity and hormone deficiency independently predicted prognosis (a 3-year survival rate of 27% was found in subjects deficient in all three hormones). Although it cannot be concluded that anabolic hormone deficiency contributes to the disease process - it may simply reflect chronic disease with no physiological consequence - it is highly plausible that deficiency may at least contribute to symptomatology. Further studies evaluating anabolic hormone replacement for symptomatic improvement and possible prognostic benefit are warranted.