Testosterone therapy and the risk of cardiovascular disease in older, hypogonadal men

• Published in: Progress in cardiovascular diseases Vol. 84; pp. 14 - 18
• Main Authors: Krishnan, Srikanth, Aldana-Bitar, Jairo, Golub, Ilana, Ichikawa, Keishi, Shabir, Ayesha, Bagheri, Marziyeh, Hamidi, Hossein, Benzing, Travis, Kianoush, Sina, Budoff, Matthew J.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-05-2024
• Subjects: Age Factors; Aged; Aging, obesity, and testosterone; Atherosclerosis and testosterone; Biomarkers - blood; Cardiovascular disease; Cardiovascular Diseases - epidemiology; Cardiovascular Diseases - prevention & control; Coronary artery calcium; Coronary artery disease; Heart Disease Risk Factors; Hormone Replacement Therapy - adverse effects; Humans; Hypogonadism; Hypogonadism - blood; Hypogonadism - drug therapy; Hypogonadism - epidemiology; Male; Middle Aged; Non-calcified plaque; Risk Assessment; Risk Factors; Testosterone - adverse effects; Testosterone - therapeutic use; Testosterone therapy; TRAVERSE trial; Treatment Outcome; CHF; TT; RCT; Atherosclerosis and testosterone; Cardiovascular disease; DM; TTrials; TRAVERSE trial; CCTA; CIMT; MACE; Testosterone therapy; TPV; TRAVERSE; Aging, obesity, and testosterone; GnRH; TEAAM; BMI; CAC; CI; Coronary artery calcium; Coronary artery disease; Hypogonadism; CVD; CV; TOM; NCP; Non-calcified plaque; LH; SHBG
• ISSN: 0033-0620; 1532-8643; 1873-1740
• DOI: 10.1016/j.pcad.2024.02.015

The debate over the cardiovascular (CV) implications of testosterone therapy (TT) have resulted in diverging safety recommendations and clinical guidelines worldwide. This narrative review synthesizes and critically evaluates long-term studies examining the effects of TT within the context of aging, obesity, and endogenous sex hormones on CV disease (CVD) risk to support informed clinical decision-making. Observational studies have variably linked low endogenous testosterone with increased CVD risk, while randomized controlled trials (RCTs) demonstrate that TT yields cardiometabolic benefits without increasing short-term CV risk. The TRAVERSE trial, as the first RCT powered to assess CVD events, did not show increased major adverse cardiac events (MACE) incidence; however, its limitations – specifically the maintenance of testosterone at low-normal levels, a high participant discontinuation rate, and short follow-up – warrant a careful interpretation of its results. Furthermore, findings from the TTrials cardiovascular sub-study, which showed an increase in non-calcified plaque, indicate the need for ongoing research into the long-term CV impact of TT. The decision to initiate TT should consider the current evidence gaps, particularly for older men with known CVD. The CV effects of maintaining physiological testosterone levels through exogenous means remain to be fully explored. Until more definitive evidence is available, clinical practice should prioritize individualized care and informed discussions on the potential CV implications of TT.