27 May Does Testosterone Lower Risk of Heart Attacks and Stroke?
Medicalresearch.com Interview with:
Robert S. Tan MD, MBA, AGSF
Clinical Director & Chief Geriatrics, Michael DeBakey VAMC
Director, Opal Medical, LLC
Clinical Professor of Family & Community Medicine, UTHSC-Houston
Associate Professor of Medicine (Geriatrics), Baylor College Medicine
Medicalresearch: What are the main findings of the study?
Dr. Tan: Our findings¹ are similar to that of an early study by Shores et al ² and other studies on endogenous testosterone that found testosterone lowered mortality. In the analysis of 39,937 patients at the Low T Centers up to 5 years, the rate ratios of new MI and strokes on testosterone as compared to general community based data sets (3,4) was 0.12 (C.I. 0.08-0.18, p<0.0001) and 0.05 (C.I 0.02-0.13, p<0.0001) respectively. Thus, there appears to be a lower risk of heart attacks and strokes with patients on testosterone. While the compared population sets are not identical or real controls; our study does suggest that rates of MI and strokes in real life practice with testosterone treated patients are even lower than the general population registries (which may include older patients).
Medicalresearch: Were any of the findings unexpected?
Dr. Tan: Yes. There have been 2 recent retrospectives studies- review of charts like ours (5,6 ) which had opposite findings. We postulate that our study differed from that of Vigen et al (5) because in our patients reached total testosterone therapeutic levels of 543 ng/dl in contrast to near hypogonadal level of 332 ng/dl in the JAMA study. Our patients were also generally younger and healthier and did not suffer from suspected coronary artery disease. In the other study by Finkel et al (6), the observation period of only up to 90 days was too short and the outcomes could be related to disease process in itself. In contrast, we followed patients up to 5 years in this study. Compliance was an issue in the other studies too and may have resulted in poor outcomes.
Medicalresearch: What should clinicians and patients take away from your report?
Dr. Tan: We should not only carefully screen and treat patients with hypogonadism, but carefully monitor them closely. If patients are given the medication, we have to ensure compliance. In addition, we should follow the guidelines (Endocrine Society, AACE, ISSAM etc.) cautiously and ensure patients reach therapeutic levels and monitor not only PSA and prostate but the hematocrit. Other co-morbid risk factors such as diabetes, hyperlipidemia and hypertension have also to be controlled. Patients should be also given lifestyle change education. The flood of media advertisement may have pushed many patients into taking testosterone, but do not be afraid to deny them of treatment if they do not qualify or have contraindications. Also, spend time educating your patient and tell them the benefits and risks. No drug is completely safe for everyone, and it is up to the practitioner to decide based on the understanding of risks/benefits by the patient and with informed consent.
Medicalresearch: What recommendations do you have for future research as a result of this study?
Dr. Tan: To be fair, we do acknowledge that perhaps the jury is perhaps still out. Although we are excited about the results of our study, it is still not known if testosterone is safe for the heart or if it can cause strokes. A large randomized, controlled study powered in the tens of thousands will be needed. To compare, the Women’s Health Initiative had 161,800 patients, studied in a prospective manner.
Tan RS, Cook K, Reilly WR. Testosterone therapy is not associated with MI or strokes. Abstract 1353. Presented at American Association Clinical Endocrinology 23rd Annual Scientific Meeting May 16th, 2014.
Shores MM, Smith NL, Forsberg CW et al. Testosterone treatment and mortality in men with low testosterone levels. J Clin Endocrinol Metab 2012;97:2050-2058.
Yeh RW, Sidney S, Chandra et al. Population trends in incidence and outcomes of Acute Myocardial Infarction. NEJM 2010; 362(23): 2155-2165.
Sacco RL1, Boden-Albala B, Gan R, et al. Stroke Incidence among White, Black, and Hispanic Residents of an Urban Community The Northern Manhattan Stroke Study. Am. J. Epidemiol. 1998; 147 (3):259-268.
Vigen R1, O’Donnell CI, Barón AE, et al. Association of testosterone therapy with mortality, myocardial infarction, and stroke in men with low testosterone levels. JAMA. 2013; 310(17): 1829-36.
Finkel WD, Greenland S, Ridgeway GK et al. Increased risk of non-fatal myocardial infarction following testosterone therapy prescription in men. PLOS ONE 2104: 9:e85805.
Abstract presented at the:
American Association of Clinical Endocrinologists (AACE) 23rd Annual Scientific and Clinical Congress
May 14 – 18, 2014;
Testosterone therapy is not associated with higher risk of myocardial infarction or stroke: the Low T experience