The Case
“I told him he never should have started that medication,” said the patient’s worried wife.
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ACEP Now: Vol 34 – No 04 – April 2015Several hours earlier, her husband had presented to the emergency department for chest pain and shortness of breath. He first noticed it over the past week when doing routine chores such as cleaning and moving furniture.
“It didn’t stop him, even though it was bothering him. He never had any serious health problems,” she said.
Other than diabetes and sleep apnea, her 62-year-old husband was healthy. His primary doctor sent him to the ED for further evaluation after a concerning ECG was obtained in his office. He was tachycardic but seemed relatively stable. We proceeded with a chest pain and dyspnea work-up, which included cardiac enzymes, chest X-ray, and a d-dimer. He waited patiently, charming the staff with his small talk and affable personality.
Enzymes were negative, and d-dimer was positive. I took him for his CT angiogram. As soon as it was done, the tech and I immediately noticed the large bilateral pulmonary emboli on the screen in front of us (see Figure 1). I was preparing to take him back to the ED when he asked, “Is there a bathroom over here? I’d rather use it here before going back to the ED. It’s pretty crowded over there.”
He had a point. The ED could be a madhouse with just two bathrooms. His wife and I assisted him to the bathroom. It was only seconds before I heard her scream. I opened the door, and he was sitting on the toilet, a glazed look on his eyes.
“I think he just passed out,” she exclaimed.
He was awake but seemed distant and tired. We helped him walk back to his stretcher. I rushed him back to the ED. IV, O2, monitor—he was still tachycardic and hypertensive. He didn’t meet criteria for lysis, so heparin was started.
Figure 1. (Left): Bilateral submassive pulmonary emboli in our patient on exogenous testosterone.
Figure 2. Repeat head CT five hours after tPA administration for treatment of pulmonary emboli and ischemic stroke.
“I told him he never should have started that medication,” his wife said.
“What do you mean?” I asked. He hadn’t told us about any medications.
“His doctor started him on something to improve his energy,” she said, explaining that a month ago he had started taking testosterone as an energy and sexual supplement.
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3 Responses to “Testosterone to Slow Aging in Men Could Pose Cardiovascular Risk”
May 3, 2015
DavidI think the article brings up some very appropriate questions but it also is a bit irresponsible. Clearly this patient suffered an PE and the cause of the PE would have needed to be investigated had he lived. The CVA that became hemorrhagic with the use of TPA is unfortunate. However, to put all this together in an article about aging and bioidentical hormone usage is a bit of a reach at this point without knowing a lot more about this patient.
While it is clear that we need a lot more research on most things we do in medicine, making the jump in this case, that PE and CVA were directly related to Testosterone or other supplements that this patient was taking is a bit of a jump. As long as this is an editorial article and not perceived as anything scientific it is up to the discretion of the editor to publish it. Aging and hormone supplements are a popular topic grabbing a lot of headlines and the center of much discussion and controversy, but the tone of the article intimates that there is a direct connect at this point. In my humble and pseudo scientific opinion, this is a bit sensationalistic and irresponsible.
May 4, 2015
Louise B Andrew MD JDThere were significant design flaws in the cited NEJM study not noted by the study authors. The test subjects were highly subject (by virtue of age, sex and inactivity) to having androgen deficiency, preexisting CV disease predisposing to subsequent events. The degree of preexisting testosterone deficiency was not assessed. The doses of exogenous testosterone greatly exceeded manufacturor’s safety recommendations. Increased activity levels following study initiation were not taken into consideration. Estradiol levels were not considered (aromatization of testosterone leads to estradiol, which predisposes to cardiovascular events in men, for example those placed on ADT).
So sweeping and unqualified generalizations could not legitimately have been arrived at by the study authors about supposed dangers of testosterone administration. The horrendous case study presented by the resident does serve to remind that a complete medication history should be elicited in any patient, and that many patients fail to mention supplements and therapies which they do not believe to be mainstream; but it does not mitigate against the use of testosterone supplementation in properly screened individuals with appropriate treatment dosage and adequate followup. Many studies have demonstrated a decrease in cardiovascular complications with testosterone supplementation, especially in diabetics. See e.g. a subsequent review article Diabetes Metab Res Rev 2012; 28(Suppl 2): 52–59.
May 6, 2015
D Johnson, MDI view this is another example of a bad outcome (ICH with 1/18 probability and a 45% mortality rate when it occurs) with the use tPA in ischemic stroke.