Can a patient receive a testosterone injection one week prior to undergoing open heart surgery, also known as coronary artery bypass grafting (CABG)?

From the Guidelines

It is strongly advised against receiving a testosterone injection one week prior to undergoing open heart surgery, also known as coronary artery bypass grafting (CABG), due to the potential increased risk of blood clots and other complications. The most recent and highest quality study, although not directly addressing testosterone therapy in the context of CABG, provides guidance on the management of patients with cardiovascular disease, emphasizing the importance of careful management of medications that may affect blood clotting or cardiovascular stability 1.

When considering the administration of testosterone therapy, it is crucial to weigh the potential benefits against the risks, particularly in patients with existing cardiovascular disease. A more recent guideline on the evaluation and management of testosterone deficiency suggests that testosterone therapy should not be commenced for a period of three to six months in patients with a history of cardiovascular events, highlighting the need for caution in patients with cardiovascular conditions 1.

Given the potential risks associated with testosterone therapy in the context of cardiovascular disease, it is recommended to stop testosterone injections at least 2-4 weeks before any major surgery, including open heart procedures, to minimize the risk of complications. Testosterone can increase the risk of blood clots, which is particularly dangerous during cardiac surgery, and may also interfere with blood pressure control and potentially interact with anesthesia medications. Additionally, testosterone affects fluid retention and electrolyte balance, which surgeons need to carefully manage during heart surgery.

Key considerations for patients undergoing CABG include:

• The management of antiplatelet therapy, with aspirin recommended to be continued preoperatively, and other antiplatelet agents such as clopidogrel and ticagrelor discontinued for at least 5 days before surgery 1.
• The potential risks and benefits of discontinuing or continuing other medications, including statins, which should not be discontinued before or after CABG in patients without adverse reactions to therapy 1.
• The importance of disclosing all medications, including hormone therapies, to the surgical team well in advance of the procedure, to allow for personalized guidance on medication management.

Ultimately, the decision to continue or discontinue testosterone therapy before CABG should be made in consultation with the patient's healthcare provider, taking into account their individual health situation and the potential risks and benefits of testosterone therapy in the context of cardiovascular disease.

From the Research

Testosterone Injections and Cardiovascular Risk

• The association between testosterone replacement therapy and cardiovascular outcomes is still unclear, with some studies suggesting a possible increased risk of cardiovascular events 2, 3, 4.
• A study published in 2020 found that preoperative testosterone use was not associated with a statistically significant increased incidence of postoperative in-hospital mortality and cardiovascular events after cardiac surgery 2.
• However, another study published in 2018 found that injected testosterone was associated with an increased risk of adverse cardiovascular events in older adult men, particularly in the immediate postinjection period 3.
• A 2013 study found that testosterone therapy was associated with an increased risk of adverse outcomes, including mortality, myocardial infarction, and stroke, among men with low testosterone levels 4.

Testosterone Therapy and Cardiovascular Safety

• A 2023 study found that testosterone-replacement therapy was noninferior to placebo with respect to the incidence of major adverse cardiac events in men with hypogonadism and preexisting or a high risk of cardiovascular disease 5.
• However, this study also found a higher incidence of atrial fibrillation, acute kidney injury, and pulmonary embolism in the testosterone group 5.
• The cardiovascular safety of testosterone-replacement therapy is still a topic of debate, and more research is needed to fully understand the potential risks and benefits 6, 5.

Testosterone Injections and Open Heart Surgery

• Based on the available evidence, it is unclear whether a patient can safely receive a testosterone injection one week prior to undergoing open heart surgery, also known as coronary artery bypass grafting (CABG) 2, 3, 4.
• The decision to administer a testosterone injection before CABG should be made on a case-by-case basis, taking into account the individual patient's medical history and risk factors 2, 3, 4.