4.3 Clinical recommendations and considerations
This systematic review highlights the importance of testosterone in relation to the electrophysiological function of the heart and makes a strong case for increasing our level of clinical consideration for testosterone as an important factor when deciding therapeutic options and susceptibility for arrhythmogenesis. There are many medications used in the treatment of both common and life-threatening conditions that have QT prolonging effects (eg. anti-arrhythmics, anti-depressants, anti-psychotics etc. – Table 3 ) (75). Hence, recognizing whether these patients are in testosterone deficient state becomes very important to reduce their risk of arrhythmogenesis (Figure 2 ). For instance, special considerations should be taken with patients undergoing androgen depravation therapy, gender transition from male to female and patients with genetic and those with medical conditions that lower their testosterone levels (eg. primary or secondary hypogonadism, liver disease) (13,25,40).
Currently there are no guidelines to perform ECGs prior to starting a potentially arrhythmogenic therapy. Additionally, there are no recommendations in regards to how patient should be counselled regarding the risk of arrhythmia development (78). It is our recommendations to assess for risk factors of QT prolongation before starting potentially arrhythmogenic therapies, if there is any suspicion for a testosterone deficient state. We encourage clinicians to perform routine ECGs before starting potentially arrhythmogenic therapies, especially on patients who may have risk factors for arrhythmogenesis and/or low testosterone (79) (Figure 4 ). For patients starting a QT prolonging medication, the British Medical Journal – Drug and Therapeutics Bulletin recommends a baseline ECG and another ECG once the drug has reached steady state (78). This paper also encourages us to keep looking into the effects of testosterone as a protective hormone against arrhythmogenesis, and its therapeutic potential. Some limitations that should be noted include the omission of gray literature and the exclusion of papers in other languages than English or Spanish.