Posts Tagged ‘myocardial infarction’

What You Need To Know About Low T (Testosterone) and Heart Disease

March 27, 2014

I have received dozens of calls from men who are concerned about the recent study that reports that testosterone replacement therapy increases the risk of heart attacks and strokes. This blog is intended to clarify some of the misinformation that is attracting so much media attention. The Androgen Study Group, a large group of physicians and researchers of which I am a member, is calling for the retraction of the paper that appeared in the Journal of American Medical Association linking testosterone and cardiovascular risks — data that its authors of the paper in the journal are standing firmly behind.

In a letter to Howard Bauchner, MD, editor-in-chief of the Journal of the American Medical Association, members of the group — formed in response to the paper and comprised of more than 125 doctors — said the study’s credibility was compromised by at least two corrections and should be pulled from the journal.
A close friend and colleague, Dr. Abraham Morgentalker pointed out the there’s no misconduct, no one faked any data, it’s just sloppy. The group called it “gross data mismanagement.”

The paper, published in JAMA in November by Michael Ho, MD, PhD, of the Eastern Colorado VA, and colleagues, found that testosterone therapy was associated with a greater risk of death, heart attack, and stroke in male veterans who’d had coronary angiography. (If the men were having coronary angiography, it stands to reason that they already had some heart disease or they wouldn’t have been subjected to this invasive procedure)

But two corrections have since been published. The first, in the Jan. 15 issue, was a clarification that the results were based on “estimates” and not raw data.

The second, which Morgentaler and colleagues focus on in their letter to the editor of the journal, involved reclassivication of patient who were excluded from the study. More than 1,000 excluded patients were assigned to different categories of exclusion, including 100 who were women!

The authors included almost 10% women in an all-male study, so why should we believe any of the other data? The Androgen Study Group points out that the data were so off that it’s hard to believe the data for the entire study are accurate.

However, Ho and colleagues said they “stand firmly by the results of our study,” noting that the overall number of excluded patients remains the same, as does the total number of included patients, and the main results of the study were not changed.

The study group said that these claims run contrary to 40 years’ worth of research on testosterone, which suggests that the hormone has some beneficial effects in certain heart patients.

But the testosterone therapy field has garnered much media attention for its financial relationships with industry. Several articles in the New York Times, including one on the marketing of “Low T”, another on the selling of testosterone gels, and an editorial, have questioned the potential overselling of the therapy.

It is true that several members of the Androgen Study Group, myself included, have relationships with testosterone drug makers, such as AbbVie, Watson, and Endo Pharmaceuticals.

It is my opinion that men who are symptomatic for low testosterone and have complaints such as lethargy, decreased libido, loss of muscle mass, and decrease in erections or potency AND who have a documented decrease in the blood level of testosterone, are good candidates for hormone replacement therapy. These men who are going to receive testosterone should have a normal digital rectal exam and a normal PSA test if they are less than 75 years of age.

Bottom Line: Low testosterone has effects that impact a man’s quality of life. If a man has symptoms of low T and a documented decrease in the blood testosterone level, he should speak to his physician about testosterone replacement therapy.

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Testosterone and Heart Disease – Facts & Caveats

January 30, 2014

I have received numerous calls from men who have symptoms of low testosterone, a documented decrease in their serum testosterone level, and who are receiving testosterone replacement therapy regarding a study that recently appeared in PLOS One.*

Let’s look at some facts. The human body is always trying to achieve homeostasis which is defined as “the ability or tendency of an organism or cell to maintain internal equilibrium by adjusting its physiological processes.” What does this mean? It means that the body is always trying to stay normal without deviations from the norm. For example, if a man drinks too much water, the kidneys will increase the excretion of water. If a man is dehydrated, the kidneys will try and conserve water to prevent the problems associated with dehydration. If a man has diabetes, the doctor will recommend a treatment to lower the blood sugar. If a man has high blood pressure, the doctor will recommend dietary changes, exercise, and perhaps medication to lower the blood pressure. If a man has anemia or a low blood count because of iron deficiency, the doctor will prescribe iron supplements. If a man has a deficiency in vitamin D, the doctor will recommend increasing the consumption of this necessary vitamin. These actions are what we do every day; we attempt to achieve a normal equilibrium in the body as this is the best way to restore and maintain health.

This same reasoning applies to men who are deficient in testosterone. Testosterone is a necessary hormone produced in the testicles that is responsible for a man’s sex drive, muscle mass, energy level, bone strength, and even a man’s mood which may cause depression if the hormone is low and not returned to normal. The unstudied/published issue is what is the target value? Most experts feel that there is no absolute “correct” value, but rather treatment is targeted at relief of symptoms.

There are more than 13 million men in the United States who reportedly suffer from testosterone deficiency. For men who receive treatment, they usually report significant improvement in their symptoms. There are many conflicting reports about testosterone and heart disease. There are even studies that support that low testosterone increases the risk of heart disease and that treating the deficiency with hormone replacement therapy may be protective of heart disease.

The study recently reported a study of the risk of acute non-fatal myocardial infarction (MI) following an initial TT prescription (N = 55,593) in a large health-care database. We compared the incidence rate of MI in the 90 days following the initial prescription (post-prescription interval) with the rate in the one year prior to the initial prescription (pre-prescription interval) (post/pre).
The results of this study in all subjects revealed the rate ratio (RR) for TT prescription was 1.36. In men aged 65 years and older, the RR was 2.19 for TT prescription. The RR for TT prescription increased with age from 0.95 for men under age 55 years to 3.43 for those aged ≥75 years. In men under age 65 years, excess risk was confined to those with a prior history of heart disease.
The study summary stated that in older men, and in younger men with pre-existing diagnosed heart disease, the risk of MI following initiation of TT prescription is substantially increased.

Some comments about the study:

No follow-up or research was done on whether or not the men on testosterone therapy achieved therapeutic levels or if they stayed on treatment. It is not accurate to assume that all men treated had their testosterone levels elevated by therapy.

There is no documentation as to whether or not Endocrine Association guidelines were followed, including morning testosterone level assessments and repeating the test at least once.

In closing, a larger study in the Journal of Clinical Endocrinology and Metabolism showed that among male veterans over 40, those on testosterone had lower rates of death than those that did not. This certainly makes sense, since hypogonadism is associated with metabolic syndrome, which is associated with an increased risk of heart attack, stroke, and death.

Finally, the International Consultation in Sexual Medicine (J Sex Med 2010;7:1608) concluded that:
• Low endogenous testosterone levels correlate with an increased risk for adverse cardiovascular events
• High endogenous testosterone levels appear to be beneficially associated with decrease mortality due to all causes, including cardiovascular disease and cancer
• Testosterone supplementation in men is relatively safe in terms of cardiovascular health
• Testosterone use in men with low testosterone leads to inconsequential changes in blood pressure, glycemic control and all lipid fractions.
Bottom Line: Low testosterone levels are associated with increased atherosclerosis. Most studies confirm that administration of testosterone to men has neutral effects on cardiovascular risk factors and cardiac events. For men with a history of heart disease, a careful discussion between the doctor and patient should take place.
*http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0085805?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+plosone%2FPLoSONE+(PLOS+ONE+Alerts%3A+New+Articles)

Take Two (Aspirins) “At Night” And You Won’t Need To Call Me In the Morning

November 22, 2013

Take Two “At Night” And You Won’t Need To Call Me In the Morning

For several decades doctors have been prescribing low dose aspirin as means to protect against heart disease. Most men, including myself, take the aspirin in the morning. The researchers wanted to see if taking aspirin at night could better thin a person’s blood and potentially lower their heart attack risks.
Since the 1980s, it’s been known that cardiovascular events happen more often in the morning. Morning hours are a peak period of activity for platelets, blood cells that aid in clotting, he said. Doctors suspect that might have a hand in the increased risk of heart attacks and strokes in the morning.
Aspirin reduces the activity of platelets, and thus reduces the chance that those platelets will clot in the bloodstream and cause a heart attack or stroke, according to the findings.

Until now most doctors didn’t feel that timing of the dose, morning or evening, would matter. That’s because aspirin has a long-lasting effect on platelets, helping thin the blood for days after it is taken.
That’s why, prior to surgery, patients are told to hold off on aspirin for five to seven days, and why it continues to thin your blood even when you miss a dose.

But the Dutch researchers found that taking aspirin at bedtime reduced platelet activity more than taking it in the morning, apparently because it headed off the body’s normal morning surge in platelet activity.
The team also found that people who took aspirin at bedtime did not suffer any more stomach upset or other side effects than people who took it in the morning,.

Cardiologists who have reviewed this report suggest that until larger follow-up studies take place, people prescribed aspirin for heart problems should continue to take it whenever in the day they like.

Bottom Line: Taking baby aspirin has an affect on blood clotting mechanism and prevents heart attacks and strokes. Since there is no disadvantage to taking the medicine at night, I plan to use this medication before going to bed. If you have any questions about this recommendation, ask your doctor

After a Heart Attack: Nine Important Steps to Follow

November 25, 2011

Heart disease is one of the most common conditions affecting middle age and older men and women. What you do after you have a heart attack (myocardial infarction) is important to your recovery and to your survival.
If you’ve just had a heart attack, how do you know whether you’re getting the best possible care? A new set of clinical performance measures can tell you whether your in-hospital treatment is on track. The measures, which were developed by the American College of Cardiology and the American Heart Association, are designed to help physicians provide optimal care for heart attack patients by outlining the key therapies that define high-quality hospital care.
• Heart Attack Step 1. You should receive aspirin when you arrive at the hospital. Studies show that aspirin reduces the risk of dying after a heart attack.
• Heart Attack Step 2. The hospital should provide clot-busting medication or angioplasty quickly. Prompt treatment is essential after a heart attack to reduce the risk of death. If you’re a candidate for clot-busting medication, you should receive it within 30 minutes of arrival at the hospital. Angioplasty with or without stenting should be done within 90 minutes of arrival.
• Heart Attack Step 3. While you’re in the hospital, you should receive a test that evaluates your heart’s pumping ability. Doctors will administer an echocardiogram, radionuclide angiogram or left ventriculogram to evaluate your heart’s left ventricular systolic function, or pumping ability.
• Heart Attack Step 4. Within 24 hours of admission, doctors should measure your total, LDL and HDL cholesterol levels as well as your triglyceride level. The results of this test will help determine your risk of a second heart attack and how aggressive your lipid-lowering therapy and dietary modifications need to be.
• Heart Attack Step 5. You should leave the hospital with prescriptions for a beta-blocker and a statin and advice to take a daily aspirin. These drugs reduce the risk of death and a second heart attack. A statin will be prescribed even if your LDL cholesterol is below 100 mg/dL.
• Heart Attack Step 6. If your heart’s pumping ability is reduced, you should also receive on discharge a prescription for an ACE inhibitor or angiotensin II receptor blocker (ARB).
• Heart Attack Step 7. If you received clot-busting medication after your heart attack, you should also receive a prescription for the antiplatelet drug clopidogrel (Plavix) when leaving the hospital. Adding Plavix to a daily aspirin further reduces the risk of heart attack in individuals treated with clot-busting medication after a heart attack.
• Heart Attack Step 8. You should receive a referral to a cardiac rehabilitation program or information about a clinical exercise program. These programs offer supervised exercise in addition to counseling on lifestyle measures, medication use and psychological issues. Make sure to follow through with your referral to cardiac rehab.
• Heart Attack Step 9. If you are a smoker, you should receive advice on smoking cessation while in the hospital. Quitting smoking is an essential part of recovering from a heart attack and has important long-term health benefits, including reducing your risk of a second heart attack.

This was excerpted from Johns Hopkins Medical Report: https://mail.google.com/mail/?hl=en&shva=1#inbox/133da74a2625336a