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Lazzerini PE, Cantara S, Bertolozzi I, Accioli R, Salvini V, Cartocci A, D'Errico A, Sestini F, Bisogno S, Cevenini G, Capecchi M, Laghi-Pasini F, Castagna MG, Acampa M, Boutjdir M, Capecchi PL. Transient Hypogonadism Is Associated With Heart Rate-Corrected QT Prolongation and Torsades de Pointes Risk During Active Systemic Inflammation in Men. J Am Heart Assoc 2021; 11:e023371. [PMID: 34935398 PMCID: PMC9075210 DOI: 10.1161/jaha.121.023371] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Systemic inflammation and male hypogonadism are 2 increasingly recognized “nonconventional” risk factors for long‐QT syndrome and torsades de pointes (TdP). Specifically, inflammatory cytokines prolong, while testosterone shortens the heart rate–corrected QT interval (QTc) via direct electrophysiological effects on cardiomyocytes. Moreover, several studies demonstrated important interplays between inflammation and reduced gonad function in men. We hypothesized that, during inflammatory activation in men, testosterone levels decrease and that this enhances TdP risk by contributing to the overall prolonging effect of inflammation on QTc. Methods and Results We investigated (1) the levels of sex hormones and their relationship with inflammatory markers and QTc in male patients with different types of inflammatory diseases, during active phase and recovery; and (2) the association between inflammatory markers and sex hormones in a cohort of male patients who developed extreme QTc prolongation and TdP, consecutively collected over 10 years. In men with active inflammatory diseases, testosterone levels were significantly reduced, but promptly normalized in association with the decrease in C‐reactive protein and interleukin‐6 levels. Reduction of testosterone levels, which also inversely correlated with 17‐β estradiol over time, significantly contributed to inflammation‐induced QTc prolongation. In men with TdP, both active systemic inflammation and hypogonadism were frequently present, with significant correlations between C‐reactive protein, testosterone, and 17‐β estradiol levels; in these patients, increased C‐reactive protein and reduced testosterone were associated with a worse short‐term outcome of the arrhythmia. Conclusions During systemic inflammatory activation, interleukin‐6 elevation is associated with reduced testosterone levels in males, possibly deriving from an enhanced androgen‐to‐estrogen conversion. While transient, inflammatory hypotestosteronemia is significantly associated with an increased long‐QT syndrome/TdP risk in men.
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Affiliation(s)
| | - Silvia Cantara
- Department of Medical Sciences, Surgery and Neurosciences University of Siena Italy
| | - Iacopo Bertolozzi
- Cardiology Intensive Therapy Unit Department of Internal Medicine Nuovo Ospedale San Giovanni di Dio Florence Italy
| | - Riccardo Accioli
- Department of Medical Sciences, Surgery and Neurosciences University of Siena Italy
| | - Viola Salvini
- Department of Medical Sciences, Surgery and Neurosciences University of Siena Italy
| | | | - Antonio D'Errico
- Department of Medical Sciences, Surgery and Neurosciences University of Siena Italy
| | - Fausta Sestini
- Department of Medical Sciences, Surgery and Neurosciences University of Siena Italy
| | - Stefania Bisogno
- Department of Medical Sciences, Surgery and Neurosciences University of Siena Italy
| | | | - Matteo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences University of Siena Italy
| | - Franco Laghi-Pasini
- Department of Medical Sciences, Surgery and Neurosciences University of Siena Italy
| | | | | | - Mohamed Boutjdir
- VA New York Harbor Healthcare SystemSUNY Downstate Health Sciences University New York NY.,NYU School of Medicine New York NY
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Hasegawa K, Ito H, Kaseno K, Miyazaki S, Shiomi Y, Tama N, Ikeda H, Ishida K, Uzui H, Ohno S, Horie M, Yokoyama O, Tada H. Impact of Medical Castration on Malignant Arrhythmias in Patients With Prostate Cancer. J Am Heart Assoc 2021; 10:e017267. [PMID: 33599136 PMCID: PMC8174268 DOI: 10.1161/jaha.120.017267] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Medical castration, gonadotropin‐releasing hormone agonists, and antiandrogens have been widely applied as a treatment for prostate cancer. Sex steroid hormones influence cardiac ion channels. However, few studies have examined the proarrhythmic properties of medical castration. Methods and Results This study included 149 patients who underwent medical castration using gonadotropin‐releasing hormones with/without antiandrogen for prostate cancer. The changes in the ECG findings during the therapy and associations of the electrocardiographic findings with malignant arrhythmias were studied. The QT and corrected QT (QTc) intervals prolonged during the therapy compared with baseline (QT, 394±32 to 406±39 ms [P<0.001]; QTc, 416±27 to 439±31 ms [P<0.001]). The QTc interval was prolonged in 119 (79.9%) patients during the therapy compared with baseline. In 2 (1.3%) patients who had no structural heart disease, torsade de pointes (TdP) and ventricular fibrillation (VF) occurred ≥6 months after starting the therapy. In patients with TdP/VF, the increase in the QTc interval from the pretreatment value was >80 ms. However, in patients without TdP/VF, the prevalence of an increase in the QTc interval from the pretreatment value of >50 ms was 11%, and an increase in the QTc interval from the pretreatment value >80 ms was found in only 4 (3%) patients. Conclusions Medical castration prolongs the QT/QTc intervals in most patients with prostate cancer, and it could cause TdP/VFs even in patients with no risk of QT prolongation before the therapy. An increase in the QTc interval from the pretreatment value >50 ms might become a predictor of TdP/VF. Much attention should be paid to the QTc interval throughout all periods of medical castration to prevent malignant arrhythmias.
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Affiliation(s)
- Kanae Hasegawa
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Hideaki Ito
- Department of Urology Faculty of Medical Science University of Fukui Japan
| | - Kenichi Kaseno
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Yuichiro Shiomi
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Naoto Tama
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Hiroyuki Ikeda
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Kentaro Ishida
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Hiroyasu Uzui
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
| | - Seiko Ohno
- Department of Bioscience and Genetics National Cerebral and Cardiovascular Center Suita Osaka Japan
| | - Minoru Horie
- Department of Cardiovascular and Respiratory Medicine Shiga University of Medical Science Otsu Japan
| | - Osamu Yokoyama
- Department of Urology Faculty of Medical Science University of Fukui Japan
| | - Hiroshi Tada
- Department of Cardiovascular Medicine Faculty of Medical Science University of Fukui Japan
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Lazzerini PE, Bertolozzi I, Acampa M, Cantara S, Castagna MG, Pieragnoli L, D'Errico A, Rossi M, Bisogno S, El-Sherif N, Boutjdir M, Laghi-Pasini F, Capecchi PL. Androgen Deprivation Therapy for Prostatic Cancer in Patients With Torsades de Pointes. Front Pharmacol 2020; 11:684. [PMID: 32477142 PMCID: PMC7239032 DOI: 10.3389/fphar.2020.00684] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/27/2020] [Indexed: 12/31/2022] Open
Abstract
Background Men normally have shorter heart rate-corrected QT interval (QTc) than women, at least in part due to accelerating effects of testosterone on ventricular repolarization. Accumulating data suggest that androgen-deprivation therapy (ADT) used for the treatment of prostatic cancer, may increase Torsades de Pointes (TdP) risk by prolonging QTc. However, the evidence for such an association is currently limited to few case reports, in most cases deriving from the analysis of uncontrolled sources such as pharmacovigilance databases. Objective To better determine the clinical impact of ADT on TdP development, we examined the prevalence of this therapy in a consecutive cohort of 66 TdP patients, prospectively collected over a ~10 years period. Methods and Results We found and described four patients who were under ADT for prostatic cancer when TdP occurred, and in two cases degenerated to cardiac arrest. Notably, in this unselected population, ADTs unexpectedly represented the second most frequently administered QT-prolonging medication in males (4/24, 17%), after amiodarone. Moreover, in the ADT patients, a blood withdrawal was performed within 24 h from TdP/marked QTc prolongation occurrence and circulating concentration of androgens and gonadothropins were measured. As expected, all cases showed markedly reduced testosterone levels (total, free, and available). Conclusion We provide evidence that a significant proportion of patients developing TdP were under treatment with ADT for prostatic cancer, thus confirming the clinical relevance of previous pharmacovigilance signals. An accurate assessment of the arrhythmic risk profile should be included in the standard of care of prostatic cancer patients before starting ADT.
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Affiliation(s)
- Pietro Enea Lazzerini
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Iacopo Bertolozzi
- Cardiology Intensive Therapy Unit, Department of Internal Medicine, Nuovo Ospedale San Giovanni di Dio, Florence, Italy
| | | | - Silvia Cantara
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Maria Grazia Castagna
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Laura Pieragnoli
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Antonio D'Errico
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Marco Rossi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.,Department of Medical Sciences, Surgery and Neurosciences, Tuscan Centre of Pharmacovigilance, Florence, Italy
| | - Stefania Bisogno
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Nabil El-Sherif
- VA New York Harbor Healthcare System, SUNY Downstate Medical Center, New York, NY, United States
| | - Mohamed Boutjdir
- VA New York Harbor Healthcare System, SUNY Downstate Medical Center, New York, NY, United States.,Division of Cardiology, Department of Medicine, NYU School of Medicine, New York, NY, United States
| | | | - Pier Leopoldo Capecchi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy.,Department of Medical Sciences, Surgery and Neurosciences, Tuscan Centre of Pharmacovigilance, Florence, Italy
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5
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Salem JE, Yang T, Moslehi JJ, Waintraub X, Gandjbakhch E, Bachelot A, Hidden-Lucet F, Hulot JS, Knollmann BC, Lebrun-Vignes B, Funck-Brentano C, Glazer AM, Roden DM. Androgenic Effects on Ventricular Repolarization: A Translational Study From the International Pharmacovigilance Database to iPSC-Cardiomyocytes. Circulation 2019; 140:1070-1080. [PMID: 31378084 DOI: 10.1161/circulationaha.119.040162] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Male hypogonadism, arising from a range of etiologies including androgen-deprivation therapies (ADTs), has been reported as a risk factor for acquired long-QT syndrome (aLQTS) and torsades de pointes (TdP). A full description of the clinical features of aLQTS associated with ADT and of underlying mechanisms is lacking. METHODS We searched the international pharmacovigilance database VigiBase for men (n=6 560 565 individual case safety reports) presenting with aLQTS, TdP, or sudden death associated with ADT. In cardiomyocytes derived from induced pluripotent stem cells from men, we studied electrophysiological effects of ADT and dihydrotestosterone. RESULTS Among subjects receiving ADT in VigiBase, we identified 184 cases of aLQTS (n=168) and/or TdP (n=68; 11% fatal), and 99 with sudden death. Of the 10 ADT drugs examined, 7 had a disproportional association (reporting odds ratio=1.4-4.7; P<0.05) with aLQTS, TdP, or sudden death. The minimum and median times to sudden death were 0.25 and 92 days, respectively. The androgen receptor antagonist enzalutamide was associated with more deaths (5430/31 896 [17%]; P<0.0001) than other ADT used for prostate cancer (4208/52 089 [8.1%]). In induced pluripotent stem cells, acute and chronic enzalutamide (25 µM) significantly prolonged action potential durations (action potential duration at 90% when paced at 0.5 Hz; 429.7±27.1 (control) versus 982.4±33.2 (acute, P<0.001) and 1062.3±28.9 ms (chronic; P<0.001), and generated afterdepolarizations and/or triggered activity in drug-treated cells (11/20 acutely and 8/15 chronically). Enzalutamide acutely and chronically inhibited delayed rectifier potassium current, and chronically enhanced late sodium current. Dihydrotestosterone (30 nM) reversed enzalutamide electrophysiological effects on induced pluripotent stem cells. CONCLUSIONS QT prolongation and TdP are a risk in men receiving enzalutamide and other ADTs. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT03193138.
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Affiliation(s)
- Joe-Elie Salem
- Assitance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit (J-E.S., X.W., E.G., F.H-L., B.L-V., C.F-B.), INSERM, Sorbonne Université, Paris, France.,Department of Medicine (J-E.S., T.Y., J.J.M., B.C.K., A.M.G., D.M.R.), Vanderbilt University Medical Center, Nashville, TN.,Department of Pharmacology (J-E.S., T.Y., B.C.K., D.M.R.), Vanderbilt University Medical Center, Nashville, TN
| | - Tao Yang
- Department of Medicine (J-E.S., T.Y., J.J.M., B.C.K., A.M.G., D.M.R.), Vanderbilt University Medical Center, Nashville, TN.,Department of Pharmacology (J-E.S., T.Y., B.C.K., D.M.R.), Vanderbilt University Medical Center, Nashville, TN
| | - Javid J Moslehi
- Department of Medicine (J-E.S., T.Y., J.J.M., B.C.K., A.M.G., D.M.R.), Vanderbilt University Medical Center, Nashville, TN
| | - Xavier Waintraub
- Assitance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit (J-E.S., X.W., E.G., F.H-L., B.L-V., C.F-B.), INSERM, Sorbonne Université, Paris, France
| | - Estelle Gandjbakhch
- Assitance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit (J-E.S., X.W., E.G., F.H-L., B.L-V., C.F-B.), INSERM, Sorbonne Université, Paris, France
| | - Anne Bachelot
- IE3M, Department of Endocrinology and Reproductive Medicine, and Centre de Référence des Maladies Endocriniennes Rares de la croissance et Centre des Pathologies gynécologiques Rares (A.B.), INSERM, Sorbonne Université, Paris, France
| | - Francoise Hidden-Lucet
- Assitance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit (J-E.S., X.W., E.G., F.H-L., B.L-V., C.F-B.), INSERM, Sorbonne Université, Paris, France
| | - Jean-Sebastien Hulot
- Université Paris-Descartes, Sorbonne Paris Cité Paris Cardiovascular Research Center, Institut national de la santé et de la recherche médicale UMRS 970, Hôpital Européen Georges Pompidou, AP-HP, Paris, France (J-S-.H.)
| | - Bjorn C Knollmann
- Department of Medicine (J-E.S., T.Y., J.J.M., B.C.K., A.M.G., D.M.R.), Vanderbilt University Medical Center, Nashville, TN.,Department of Pharmacology (J-E.S., T.Y., B.C.K., D.M.R.), Vanderbilt University Medical Center, Nashville, TN
| | - Benedicte Lebrun-Vignes
- Assitance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit (J-E.S., X.W., E.G., F.H-L., B.L-V., C.F-B.), INSERM, Sorbonne Université, Paris, France
| | - Christian Funck-Brentano
- Assitance Publique Hopitaux de Paris, Pitié-Salpêtriére Hospital, Departments of Pharmacology and Cardiology, UNICO-GRECO Cardio-oncology Program, Centre d'investigation clinique-1421, Pharmacovigilance Unit (J-E.S., X.W., E.G., F.H-L., B.L-V., C.F-B.), INSERM, Sorbonne Université, Paris, France
| | - Andrew M Glazer
- Department of Medicine (J-E.S., T.Y., J.J.M., B.C.K., A.M.G., D.M.R.), Vanderbilt University Medical Center, Nashville, TN
| | - Dan M Roden
- Department of Medicine (J-E.S., T.Y., J.J.M., B.C.K., A.M.G., D.M.R.), Vanderbilt University Medical Center, Nashville, TN.,Department of Pharmacology (J-E.S., T.Y., B.C.K., D.M.R.), Vanderbilt University Medical Center, Nashville, TN.,Department of Biomedical Informatics, Vanderbilt University Medical Center (D.M.R.), Vanderbilt University Medical Center, Nashville, TN
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