Low testosterone is associated with an increased risk of MACE lethality in subjects with erectile dysfunction
Giovanni Corona1,2,5, Matteo Monami3,5, Valentina Boddi1,5, Alessandra Fisher1,5, Giulia De Vita1,5, Cecilia Melani4,5, Daniela Balzi4,5, Alessandra Sforza2,5, Gianni Forti1,5, Edoardo Mannucci3,5 & Mario Maggi1,5
Introduction: Although testosterone has been suggested to play a protective role against the development of atherosclerosis, studies demonstrating an association between low testosterone, and incident major adverse cardiovascular events (MACE) are scanty in the general population and absent in subjects with erectile dysfunction (ED). The aim of this study is to investigate whether low testosterone in subjects with ED predict incident fatal or non fatal MACE.
Methods: This is an observational prospective cohort study evaluating a consecutive series of 1687 patients attending our Andrological Unit for ED. Patients were interviewed using SIEDY and ANDROTEST structured interviews measuring components relative to ED and hypogonadal-related symptoms, respectively. Total testosterone was evaluated at baseline. Information on MACE was obtained through the City of Florence Registry Office.
Results: Among the patients studied 5.2, 13.8 and 22.4% were hypogonadal according to different thresholds (testosterone <8, 10.4 and 12 nmol/l or 230, 300 and 350 ng/dl, respectively). During a mean follow-up of 4.3±2.6 years, 139 MACE, 15 of which were fatal, were observed. Unadjusted incidence of MACE was not associated with T levels. Conversely, the proportion of lethal events among MACE was significantly higher in hypogonadal patients, using either 10.4 nmol/l (300 ng/dl) or 8 nmol/l (230 ng/dl) thresholds. However, after adjustment for age and Chronic diseases score in a Cox regression model, only the association between incident fatal MACE and testosterone <8 nmol/l (230 ng/dl) was confirmed (HR=7.1 (1.828.6); P<0.001). Interestingly, measuring hypogonadal-related symptoms and signs through ANDROTEST, only fatal MACE were also associated with a higher score (HR=1.2 (1.01.5) for each ANDROTEST score increment; P=0.05 after adjustment for age and Chronic diseases score).
Conclusions: Testosterone levels are associated with a higher mortality of MACE. The identification of low testosterone levels should alert the clinician thus identifying subjects with an increased cardiovascular risk.