Is there an association between testosterone replacement therapy (TRT) and palpitations, specifically tachycardia?

From the Guidelines

Testosterone replacement therapy (TRT) may be associated with an increased risk of cardiovascular events, including palpitations and tachycardia, although the evidence is of low certainty. According to a 2020 study published in the Annals of Internal Medicine 1, the pooled risk for adverse cardiovascular outcomes did not differ significantly between groups receiving TRT and placebo, but the incidence of cardiovascular events was higher in the testosterone group.

Key Considerations

• The study found that the incidence of cardiovascular events was 2.3% in the testosterone group, compared with 1.5% in the placebo group 1.
• The evidence for the primary harm outcomes, including cardiovascular events, was of low certainty due to the variability in study definitions, adjudication, and follow-up duration 1.
• A more recent study published in 2024 in Diabetes Care 1 discusses the benefits and risks of testosterone replacement in men with symptomatic hypogonadism, but does not specifically address the association between TRT and palpitations.

Clinical Implications

• If you are experiencing palpitations while on testosterone therapy, you should contact your healthcare provider promptly for evaluation.
• Your doctor may need to adjust your dosage, change your administration method, or monitor your hormone levels more closely.
• Common testosterone preparations include injectable testosterone cypionate, testosterone gel, or testosterone patches.
• Palpitations might occur due to testosterone's effects on red blood cell production, electrolyte changes, or direct cardiac stimulation.
• Your doctor should check your hematocrit, electrolytes, and possibly perform cardiac monitoring to rule out underlying conditions that may be contributing to palpitations.

From the FDA Drug Label

5.5 Cardiovascular Risk The FDA drug label does not answer the question.

From the Research

Association between Testosterone Replacement Therapy (TRT) and Palpitations

• There is no direct evidence in the provided studies to suggest a specific association between TRT and palpitations, specifically tachycardia 2, 3, 4, 5, 6.
• However, some studies suggest that TRT may be associated with higher cardiovascular risks, including adverse cardiovascular events such as myocardial infarction, stroke, and all-cause mortality 2, 5.
• A study published in 2023 found that TRT was not observed to confer a protective or adverse effect on the risk of myocardial infarction, stroke, or all-cause mortality in hypogonadal men with a modest prevalence of established cardiovascular disease 5.
• Another study published in 2023 found that TRT 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 6.
• The study also found a higher incidence of atrial fibrillation in the TRT group, which may be related to palpitations 6.

Cardiovascular Risks and TRT

• The effects of TRT on the heart remain controversial, with some studies suggesting cardioprotective effects and others suggesting adverse effects 3.
• A review of the literature suggests that chronic TRT at a physiological dose may demonstrate cardioprotective effects, whereas acute TRT can cause adverse effects in the heart 3.
• The use of TRT to achieve physiologic testosterone concentrations in men does not pose a threat to cardiovascular health and has demonstrated a cardioprotective effect 4.