Testosterone vs Heart Failure

Click here for April 19, 2012 update!

I mentioned in an earlier post that I was attending a CME conference last week. One of the lectures covered evidence-based, state of the art care of patients with heart failure. The presenter reminded us that ACE inhibitors, beta blockers & aldosterone antagonists, separately and in combination, have been demonstrated to improve heart failure mortality. He also reviewed evidence that the benefit from beta blockers is not a class effect since there are real differences between the individual drugs. Cardiac resynchronization therapy plus implantable cardioverter-defibrillators has also been demonstrated to improve outcomes.

All told, he pointed out a 77% cumulative risk reduction if all four of these therapies were applied with 27% absolute risk reduction. This translates into treating only 4 persons in order to save 1. Given that heart failure exacerbation is one of the leading causes of (re)hospitalization and that hospital care accounts for the greatest percentage of medical costs, it's clear that we need to be more aggressive in optimally treating our patients with heart failure.

However, he also pointed out that current ACC guidelines do not recommend hormonal therapies other than to replace deficiencies. Based upon the preponderance of new information, I have to disagree. For instance, in a study published just last month, researchers randomized 36 elderly women with stable heart failure (NYHA III without hospitalization in immediate past 3 months with 33% ejection fraction) on maximal medical management to either testosterone transdermal patch (300ug twice weekly) or to placebo and followed them for 6 months.

Those who received testosterone walked further in 6 minutes (standard testing protocol), increased their maximum oxygen consumption (that's a good thing), and strengthened their legs.  If you ask me, that's a touchdown or home run, especially when your average age is 68-69yo.  Even better, no side effects were reported from this dose besides minor allergic dermatitis, common to all patch delivery systems.

Not surprisingly, these findings are consistent with those published last September in which 70 elderly men (average 70yo) with heart failure (NYHA II or III with 32% ejection fraction) responded to intramuscular testosterone for 12 weeks on top of maximal medical management.  They, too, demonstrated improvement in exercise capacity, muscle strength, and even glucose metabolism.  And just as important, the therapy was well tolerated.

In January 2006, 76 men (average 64yo) with heart failure (NYHA II-IV with 32% ejection fraction) were randomized to receive Androderm 5mg daily vs placebo for 12 months.  The authors reported significant improvement in functional capacity as born out by decrease in NYHA classification.  The only issue noted was intolerance to the patch.

Finally, a study in May 2003 demonstrated in 12 men with heart failure that testosterone 60mg via buccal mucosa increased cardiac output immediately.

Now, I'm not suggesting that everyone with heart failure go out and start taking testosterone.  However, I think that the research thus far points to a need for a larger scale study of longer duration to confirm/disprove these consistent results using a very inexpensive drug.  And in the meantime, for those of you waiting for the outcome of said study, perhaps you can discuss the above findings with your cardiologist or primary care provider.