SUN-206 Acute Cardiovascular Complications FromTestosterone Therapy

Background: Some studies have suggested Testosterone (T), especially parenteral administration may increase the short-term risk of thromboembolic events. We report 2 patients who developed acute cardiovascular complications following treatment with intramuscular injection of T. Case 1: A 43-year-old man was evaluated for erectile dysfunction and fatigue. History was significant for hypercholesterolemia treated with atorvastatin. On physical examination, vital signs, heart and lung examinations were normal. Testicular volume was 15 mL bilaterally. Lab revealed normal CBC, liver function, creatinine, and iron studies. A serum T level at 7am was 140 ng/dL; FSH 4.2mIU/mL, LH 3.8 mIU/mL, prolactin and TFT were normal. Pituitary MRI was normal. Patient was started on T enanthate 200 mg IM every 2 weeks. 6 weeks later, serum T level (obtained 7 days after injection) revealed a value of 480 ng/dL. 2 months following treatment the patient noted significant improvement. Four months after T treatment patient developed acute chest pain followed by cardiac arrest. Despite resuscitation, the patient expired after 45 minutes. Autopsy confirmed obstructions of left anterior descending coronary artery and right coronary artery. Case 2: A 48-year-old man was evaluated for erectile dysfunction and generalized muscle weakness. Past history and family history were noncontributory. Physical examination revealed normal vital signs and examination of the heart, lungs and abdomen was normal. Right testis 10 mL and left testis 15 mL in size. Lipid panel showed LDL 110 mg/dL, HDL 48 mg/dL. Serum T level at 8am was 135 ng/dL, FSH 3.1 mIU/mL, LH 2.8 mIU/mL, prolactin and TFT were normal. A pituitary MRI showed an empty sella. Patient was started on T injection 100 mg every 10 days. Six weeks later follow-up serum T (5 days after injection) was 466 ng/dL and serum estradiol was 39 pg/mL. Six months later he developed acute dyspnea and tachycardia. D-dimer value was 3260 ng/mL. CT angiogram revealed a thrombus in one of the left lower lobe pulmonary artery branches. Patient was treated in the intensive care unit with supportive care and anticoagulation. Follow-up evaluation confirmed factor V Leiden mutation. Discussion: T replacement is commonly given for hypogonadism but clinicians need to be aware of the potential rare adverse side effects such as acute cardiac events, as described in these 2 otherwise healthy patients with no known risk factors. In the second patient serum estradiol which may contribute to thrombosis was normal. The mechanism of these CV effects are unknown, but may be due to increased expression of platelet thromboxane A2 receptor and/or via other mechanisms especially in patients with procoagulant predisposition.