Jump to comment:

• Authors reply: Low sex hormones in heart failure
  Gulmisal Guder
  Published on: 23 November 2015

• Published on: 23 November 2015

  Authors reply: Low sex hormones in heart failure

  • Gulmisal Guder
  • Other Contributors:
    • Bruno Allolio, Georg Ertl, Christiane E Angermann, Stefan Stork

  In their recent editorial in this Journal Theodoraki and Bouloux [1] question the cut-off values employed in our article on the association between circulating androgens and mortality risk in heart failure (HF).[2] While we (according to our local Central Hospital Laboratory) defined androgen deficiency by total testosterone values <180 ng/dl for patients >50 years and 260 ng/dl for younger patients, and by free te...

  Show More

  In their recent editorial in this Journal Theodoraki and Bouloux [1] question the cut-off values employed in our article on the association between circulating androgens and mortality risk in heart failure (HF).[2] While we (according to our local Central Hospital Laboratory) defined androgen deficiency by total testosterone values <180 ng/dl for patients >50 years and 260 ng/dl for younger patients, and by free testosterone values <9 ng/dl, Theodoraki and Bouloux - referencing Wang et al. [3] - suggest a more liberal and age-independent cut-off value for total testosterone (<230 ng/dl), but a more restrictive cut-off level for free testosterone (<6.5 ng/dl). If these alternative cut-off levels were applied to our data, prevalence of androgen deficiency defined by total testosterone would hardly be affected (15 instead of 9%), while it would be markedly reduced if defined by free testosterone (from 79 to 51%). Since we performed all survival analyses using continuous rather than categorized variables, however, these considerations do not affect the main finding of our study, namely the lacking association between androgen levels and mortality risk after adjustment for important confounders. We agree, however, that reaching a consensus on both standardized testosterone measurement and definition of (possibly age- dependent) cut-off values is mandatory in order to establish direct comparability between studies.

  Current guidelines advocate testosterone replacement only in "symptomatic" patients with repeatedly "low" testosterone levels.[4] HF, like any chronic illness, profoundly affects sex steroid metabolism, and better understanding of underlying pathologies is warranted to disentangle the cause-effect relations in this situation. Theodoraki and Bouloux build their line of arguments on two small trials on testosterone therapy in patients with HF, which were considered positive as they improved patients' symptoms. However, the authors omit to comment on the liberal inclusion criteria not demanding established testosterone deficiency (in both studies prevalence of androgen deficiency <30%), and on the very high drop-out rate in one study. We would conclude that liberal testosterone therapy in patients with HF is presently not justified since conclusive evidence of benefit is lacking, pathophysiology is ill understood, and important safety concerns are unresolved.[4, 5]

  1 Theodoraki A, Bouloux PM. Low sex hormones in heart failure. Heart;96:496-7.

  2 Guder G, Frantz S, Bauersachs J, et al. Low circulating androgens and mortality risk in heart failure. Heart;96:504-9.

  3 Wang C, Nieschlag E, Swerdloff R, et al. ISA, ISSAM, EAU, EAA and ASA recommendations: investigation, treatment and monitoring of late-onset hypogonadism in males. Int J Impot Res 2009;21:1-8.

  4 Bhasin S CG, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, Montori VM. Testosterone Therapy in Men with Androgen Deficiency Syndromes: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2010;Jun;95(6)::2536-59.

  5 Basaria S, Coviello AD, Travison TG, et al. Adverse events associated with testosterone administration. N Engl J Med;363:109-22.

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top