But things turn on a dime. While the heparin drip was running, something happened. The talkative man from before was now on a stretcher and unable to speak or move his right side. First a pulmonary embolism, now a stroke? We stopped the heparin and rushed him to CT. He was negative for bleed. This was not particularly reassuring and didn’t lessen our dilemma. It was clear he was having an ischemic stroke. Neurology, the ED team, and his family had a long discussion about treatment options—tPA or not? Given his concurrent submassive bilateral pulmonary emboli and a presumed ischemic stroke with significant functional morbidity, his family consented to thrombolysis.
Explore This Issue
ACEP Now: Vol 34 – No 04 – April 2015He remained awake but still unable to speak as the tPA was administered. He was able to follow commands with his unaffected side.
Five hours later, a repeat head CT confirmed our most-feared outcome: hemorrhagic conversion of his left middle cerebral artery infarct (see Figure 2). Efforts were made to reverse the tPA without success. The damage was done. During his hospital stay, he was intubated for airway protection but never improved. He eventually died on day nine.
Discussion
The use of testosterone to slow the aging process in men has recently increased in popularity. US testosterone prescription sales totaled a whopping $2.4 billion in 2013 alone. Time magazine’s 2014 article “Manopause?! Aging, Insecurity and the $2 Billion Testosterone Industry” brought national attention to the increasing off-label use of the drug and the birth of an industry for aging men.1
Turn on the TV, and you will frequently see ads with fresh-faced older men running through meadows, enjoying a renewal of energy and youth. Testosterone is one of the drugs people associate with the Fountain of Youth. Now, the use of exogenous androgens for treating primary medical disease is all but a footnote in the practice of medicine.
Unfortunately, little research has been done to demonstrate the benefits of testosterone to reduce the symptoms of the natural aging process in men. Studies published recently have drawn scrutiny to this practice, hypothesizing the increased risk of cardiovascular events with the use of exogenous testosterone.2,3 The Food and Drug Administration has taken notice, calling for an investigation to determine the potential risks.
However, advocates of exogenous testosterone therapy have recently published data suggesting the opposite. They contend testosterone does not increase cardiovascular risk and may even protect against it.4
Needless to say, much has yet to be determined. Randomized clinical trials now must disregard precedent, where benefit has been presumed, and fully examine harm. An earlier trial was terminated early due to the harm seen in the group receiving testosterone.5
Pages: 1 2 3 | Single Page
3 Responses to “Testosterone to Slow Aging in Men Could Pose Cardiovascular Risk”
May 3, 2015
DavidI think the article brings up some very appropriate questions but it also is a bit irresponsible. Clearly this patient suffered an PE and the cause of the PE would have needed to be investigated had he lived. The CVA that became hemorrhagic with the use of TPA is unfortunate. However, to put all this together in an article about aging and bioidentical hormone usage is a bit of a reach at this point without knowing a lot more about this patient.
While it is clear that we need a lot more research on most things we do in medicine, making the jump in this case, that PE and CVA were directly related to Testosterone or other supplements that this patient was taking is a bit of a jump. As long as this is an editorial article and not perceived as anything scientific it is up to the discretion of the editor to publish it. Aging and hormone supplements are a popular topic grabbing a lot of headlines and the center of much discussion and controversy, but the tone of the article intimates that there is a direct connect at this point. In my humble and pseudo scientific opinion, this is a bit sensationalistic and irresponsible.
May 4, 2015
Louise B Andrew MD JDThere were significant design flaws in the cited NEJM study not noted by the study authors. The test subjects were highly subject (by virtue of age, sex and inactivity) to having androgen deficiency, preexisting CV disease predisposing to subsequent events. The degree of preexisting testosterone deficiency was not assessed. The doses of exogenous testosterone greatly exceeded manufacturor’s safety recommendations. Increased activity levels following study initiation were not taken into consideration. Estradiol levels were not considered (aromatization of testosterone leads to estradiol, which predisposes to cardiovascular events in men, for example those placed on ADT).
So sweeping and unqualified generalizations could not legitimately have been arrived at by the study authors about supposed dangers of testosterone administration. The horrendous case study presented by the resident does serve to remind that a complete medication history should be elicited in any patient, and that many patients fail to mention supplements and therapies which they do not believe to be mainstream; but it does not mitigate against the use of testosterone supplementation in properly screened individuals with appropriate treatment dosage and adequate followup. Many studies have demonstrated a decrease in cardiovascular complications with testosterone supplementation, especially in diabetics. See e.g. a subsequent review article Diabetes Metab Res Rev 2012; 28(Suppl 2): 52–59.
May 6, 2015
D Johnson, MDI view this is another example of a bad outcome (ICH with 1/18 probability and a 45% mortality rate when it occurs) with the use tPA in ischemic stroke.