One of the reasons I wanted to start this channel was because of my frustration at how limited we were when it came to treating heart disease patients. Of course one of the reasons for this is that we simply don’t know enough but another reason was that medicine as a whole has become very defensive. Offer the patient only those therapies which are recommended by clinical guidelines because that is medicolegally defensible. Never step outside of the guidelines for the sake of that individual patient because you could get into trouble. What this has resulted in is the belief that if the therapy is not recommended in the guidelines then it’s not even worth having a conversation about. This is why I wanted to empower patients who continue to be troubled despite being on guideline recommended therapies by telling them about all the other therapies that may be helpful which have not made it into the guidelines.
Today’s video is on the subject of heart failure.
Heart failure is a chronic clinical syndrome characterised by the inability of the heart to pump out enough blood to meet the body’s requirements. In that sense, it is the end-complication of virtually all cardiac pathology. If you have a big heart attack for example, and survive it, then the concern is that the concern is that the damage caused to the heart may lead to the heart not being able to work as effectively as a pump and this is called heart failure. Similarly myocarditis which is inflammation of the heart, if severe affects the heart’s ability to pump effectively and leads to heart failure. Anything that affects the heart in a bad way may in its severest form lead to heart failure.
Unfortunately the term ‘heart failure’ has unnecessarily negative connotations- a better term is cardiac insufficiency. The heart hasn’t failed – it just doesn’t match up to the body’s requirements especially when the requirements are increased such as during exercise.
Heart failure or cardiac insufficiency has marked negative effects both on quality of life and quantity of life. People with a weak heart do not in general live as long as those with a strong heart and people with a weak heart will in general have a significantly worse quality of life compared to those with a strong heart. It is also important to know that heart failure is a multi system disorder. Because the heart is responsible for pumping blood to the rest of the body, virtually all systems of the body suffer as a consequence of heart failure. So people with heart failure are going to be more prone to kidney failure and dementia and strokes and muscle wasting and anaemia and they may also develop hormonal deficiencies and these complications will have an additional negative effect on both quality and quantity of life.
Heart failure is one of the most researched conditions in all of medicine and happily we now have lots of very beneficial therapies which can improve both quality of life and prognosis. These include ACE inhibitors (medications such as ramipril, lisinopril, perindopril etc), beta-blockers (carvedilol, Bisoprolol, nebivolol), aldosterone antagonists (spironolactone), Entresto and now there is a new class of medications called SGLT2 inhibitors such as Dapagliflozin.
Nevertheless despite all these medications, patients with significant heart failure may continue to deteriorate, lose muscle mass and strength, get frailer, weaker and have an ever-worsening quality of life. This increasing frailty also contributes to the very high mortality rates of up to 30% per year. We therefore urgently need more therapies that may improve quality of life in these patients.
This is why I wanted to talk to you about Testosterone.
As healthy men age, there is a fall in testosterone and alongside this there is a decrease in muscle mass, muscle strength and lower extremity strength. When we give testosterone to healthy men with testosterone deficiency, we see an increase in lean body mass and muscle mass.
Now when we look at heart failure patients, we find that up to 26-37% of patients have testosterone deficiency. Low testosterone levels are associated with increased systemic vascular resistance (this means it is even harder for the heart to pump blood to the vital organs) and reduced heart rate variability. In addition, testosterone is recognised to have anti-inflammatory properties and therefore patients with low testosterone may have higher levels of inflammation. Clinically patients who have heart failure and are deficient in testosterone will have more muscle wasting, reduced exercise capacity and worse quality of life.
When testosterone is given intravenously , we see that the systemic vascular resistance decreases and the output of the heart improves. When testosterone is given over a period of time, we see that inflammation as measured by inflammatory blood markers (TNF alpha and interleukin 1-beta) is seen to fall.
There have been a few studies looking at testosterone replacement in men with heart failure and although the studies are very small, the results are certainly very interesting.
There was a meta-analysis in the journal of American College of Cardiology in 2016 which looked at all the studies regarding had been done until then and concluded that replacement with transdermal or intramuscular testosterone resulted in a significant improvement in exercise capacity. 6 minute walk test distances increased by 54meters, incremental shuttle walk tests increased by 46.7 meters. These improvements were comparable to some of the most effective licenced medications for heart failure. In addition, quality of life markedly improved in 35% of patients in the TRT group.
More importantly there was no increase in adverse events in the TRT group compared to placebo.
One of the very important observations to mention is that the benefits of testosterone supplementation in heart failure may not just be limited to male patients.There was an interesting small study published in the journal of the American college of cardiology which showed that testosterone supplementation in women also improved functional capacity and muscle strength in women with advanced heart failure.
Whilst these are promising data, unfortunately not many people look for or treat testosterone deficiency in patients with heart failure and this is because most doctors tend to be protocol-centered rather than patient-centered and at present checking for testosterone levels routinely and treating testosterone deficiency has not made it into protocols. We will need bigger studies to understand the benefits and cost-effectiveness of testosterone replacement before our learned ‘experts’ who author these protocols will decide to change the status quo.
If you have heart failure or have a relative who has heart failure and who is continuing to struggle despite medications, it would certainly be an excellent idea to ask your doctor to measure testosterone levels in the first instance. Your doctor will not do it routinely and therefore it is important you ask them to. If it is low, it would certainly be worth having a conversation about the points I have discussed in this video.
Thank you for reading. I appreciate you more than you will ever know.
Keywords: testosterone; heart failure; dr sanjay gupta; yorkcardiology; cardiomyopathy