Evaluation and Management of Testosterone Deficiency: AUA Guideline.

PURPOSE: There has been a marked increase in testosterone prescriptions in the past decade resulting in a growing need to give practicing clinicians proper guidance on the evaluation and management of the testosterone deficient patient. MATERIALS AND METHODS: A systematic review utilized research from the Mayo Clinic Evidence Based Practice Center and additional supplementation by the authors. Evidence-based statements were based on body of evidence strength Grade A, B, or C and were designated as Strong, Moderate, and Conditional Recommendations with additional statements presented in the form of Clinical Principles or Expert Opinions (table 1 in supplementary unabridged guideline, http://jurology.com/). RESULTS: This guideline was developed by a multi-disciplinary panel to inform clinicians on the proper assessment of patients with testosterone deficiency and the safe and effective management of men on testosterone therapy. Additional statements were developed to guide the clinician on the appropriate care of patients who are at risk for or have cardiovascular disease or prostate cancer as well as patients who are interested in preserving fertility. CONCLUSIONS: The care of testosterone deficient patients should focus on accurate assessment of total testosterone levels, symptoms, and signs as well as proper on-treatment monitoring to ensure therapeutic testosterone levels are reached and symptoms are ameliorated. Future longitudinal observational studies and clinical trials of significant duration in this space will improve diagnostic techniques and treatment of men with testosterone deficiency as well as provide more data on the adverse events that may be associated with testosterone therapy.

Heart failure with preserved left ventricular function: diagnostic and therapeutic challenges in patients with diastolic heart failure.

Heart failure associated with preserved left ventricular ejection fraction (HFpEF) is a condition of increasing importance, not only due to its rising prevalence but also due to the lack of clinical evidence for pharmacologic therapies that are beneficial. Thus, a recent case encountered at the Vanderbilt University Medical Center illustrates the clinical challenges one may encounter in patients with HFpEF. A careful review of the diagnostic challenges of HFpEF or diastolic heart failure, current recommendations for management and a glimpse of upcoming research are presented.

Oral postmenopausal hormone therapy, C-reactive protein, and cardiovascular outcomes.

OBJECTIVES: This study examines C-reactive protein (CRP) levels predicting cardiovascular events (CVEs) among hormone therapy (HT) users and nonusers. METHODS: CRP levels are higher in women who use oral HT than those in nonusers; however, whether the same CRP cut-points determine increased cardiovascular risk remains unanswered. CRP was measured at baseline in 10,953 HT users and 15,838 nonusers in the Women's Health Study. In HT nonusers and users, Cox proportional hazard models adjusted for age, cardiovascular risk factors, body mass index, and menopause status were constructed using American Heart Association/Centers for Disease Control and Prevention recommended CRP cut-points for low, average, and high cardiovascular risk as well as HT nonuser- and user-derived quantiles of CRP to predict incident CVEs. RESULTS: CVE risk increased with logarithm CRP for both HT users and nonusers. After adjusting for cardiovascular risk factors including lipids, the multivariable relative risk (RR) per log unit of CRP was 1.27 (95% CI, 1.13-1.44) for HT nonusers and 1.22 (95% CI, 1.07-1.40) for HT users. To compare the risk associated with American Heart Association/Centers for Disease Control and Prevention CRP categories across HT use groups, we fit a model in which nonusers with a CRP level lower than 1 mg/L were the reference group. After adjusting for other risk factors including lipids, HT users with a CRP level of 3 mg/L or higher had an RR of 1.93 (1.38-2.69), whereas nonusers had an RR of 1.92 (1.35-2.72). CONCLUSIONS: CRP predicts CVE in a linear relationship among both HT users and nonusers. CRP levels of 3 mg/L or higher were associated with increased cardiovascular risk in both nonusers and HT users.

Extent and distribution of coronary artery disease: a comparative study of invasive versus noninvasive angiography with computed angiography.

BACKGROUND: The extent and nature of overall coronary artery disease (CAD), defined as the cumulative stenotic and nonstenotic, calcified and noncalcified atherosclerosis burden, are underestimated by invasive coronary angiography (ICA) and more accurately quantified with intravascular ultrasound. Multidetector row computed tomography (MDCT) is inferior to intravascular ultrasound but may constitute an attractive noninvasive alternative to assess overall CAD burden. METHODS: To compare ICA with MDCT for detection of CAD (defined as luminal narrowing of any degree or calcification by ICA and any atherosclerotic plaque detection by MDCT using the 17-segment model), we studied 37 patients (age, 63 +/- 11 years) who underwent both tests. RESULTS: A total of 508 of 586 (87%) segments were assessable, and CAD was detected in 121 of 508 (24%) segments by ICA versus 338 of 508 (67%) by MDCT (P < .01). Of the 121 segments positive for CAD by ICA, MDCT detected plaques in 117 segments (97%). In the 387 of 508 (76%) segments that were free of CAD by ICA, MDCT detected CAD in 221 (57%) segments. Overall, ICA detected CAD in only 20%, 48%, and 46% of segments with noncalcified, calcified, and mixed plaques, respectively, seen by MDCT (P = .01). Of the 221 segments negative for CAD by ICA, 119 (54%) were positively remodeled on MDCT. Overall correlation between ICA and MDCT for detection of CAD was poor (kappa = 0.25). CONCLUSIONS: Invasive coronary angiography and MDCT differ significantly in estimating the presence and nature of CAD. Multidetector row computed tomography may provide an attractive noninvasive alternative to ICA to assess the effects of medical therapy.