Prof. Stephan von Haehling MD PhD DIC FESC FHFA - INTERVIEW
STEPHAN VON HAEHLING: I have a strong interest in heart failure, and my main area of expertise is really heart failure, so many of my patients have heart failure, and these patients are, in many cases, coming along with comorbidities.
These comorbidities are coming from a very broad field across nephrology, across rheumatology, but in particular, patients also have problems with their exercise capacity and muscle strength. So, we invested the prevalence of muscle wasting in heart failure patients of my group, and we found a very high prevalence of almost 20 percent of sarcopenia, ie. muscle wasting, in ambulatory patients with heart failure. And this really sparked my interest in why is there such a high prevalence of skeletal muscle wasting, and does this have a strong effect on the patient’s wellbeing and quality of life? And the answer was really “yes”. So, one of the questions was, is there any treatment for this problem, and testosterone might really be an option, because testosterone is an anabolic steroid, and as such, it may really have a positive effect on muscle mass and muscle strength. For that purpose, of course, I screened literature, there’s a number of smaller studies that were published in 2008, 2009 in roughly 150 patients with heart failure. So, the idea arose that hypogonadism in these patients may be prevalent; and particularly, these patients may benefit from treatment.
Well, patients with heart failure who are on an ambulatory basis have a high likelihood of hypogonadism simply because many of these patients are elderly males. Roughly 70 percent of heart failure patients are males, and most of these patients are above 60. Many of them are above 70 years of age. So, my recommendation would be to screen very broadly. Heart failure patients, particularly those who have heart failure with reduced ejection fraction, and particularly in those who are above 70 years, and if they complain about problems with exercise capacity, if they complain about muscle weakness, I would definitely screen for the prevalence or presence of hypogonadism and testosterone deficiency.
Well, cardiovascular benefits is a difficult task really to touch upon. What I believe for the heart failure patients is that they may have a strong benefit with regards to the exercise capacity, as it has been shown in smaller studies. We do not know a lot about how patients’ cardiovascular function parameters may benefit. So, we don’t know about left ventricular ejection fraction, we don’t know about NT ProBNP values, simply because these have not been routinely measured in clinical studies. However, what we know is that heart failure patients have an increase in their spirometry, peak VO2 value. So, exercise capacity is objectively increasing. And also, we have data from randomized controlled trials, placebo-controlled trials that show that the six-minute walk distance is improving, and it’s improving to a very significant extent. In small studies, we have seen increases by about 80 meters over a timeframe of three months, which is – well, I’m tempted to call this incredible because the usual increase in the six-minute walk distance in other trials is about 30 meters or 40 meters. So, this is quite a significant increase.
Well, I think that clinical studies using testosterone or maybe other anabolics in patients with heart failure are urgently needed, because this might be a way of improving exercise capacity, particularly in those patients who are very symptomatic; and it would be great to organize and plan a study using a testosterone treatment in patients with advanced heart failure, particularly in those of reduced ejection fraction and with symptomatic heart failure, meaning New York Heart Class II or above. There are several ways of applying testosterone. And interestingly now, there’s even one small study in, I think, 30 women that has shown that testosterone treatment using transdermal patches was even beneficial, in these patients.
I think with regards to the screening for hypogonadism, cardiologists come in when it comes to heart failure patients, because heart failure patients have a very high prevalence and burden of comorbidities, and comorbidities—so many comorbidities—in heart failure patients, it is difficult to really keep track of all of them for the cardiologist. But apart from the, well, usual suspects, such as kidney failure, diabetes, COPD in these patients, we also need for the unexpected suspects, such as hypogonadism. So, we should really implement such recommendations into the guidelines that not tell us to screen for iron deficiency, which has been implemented only a couple of years ago, but also for unusual or the not-so-commonly known comorbidities, and this also includes hypogonadism. But, I think this should be implemented into the guideline, and for that, we need better powered studies, which are hopefully underway soon.
Prof. Dr. med. Marija Pfeifer Medical Faculty University of Ljubljana, Slovenia