GH Therapy in Chronic Heart Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Testosterone replacement therapy in heart failure: A systematic review of randomized controlled trials

INTRODUCTION

Heart failure (HF), a leading cause of morbidity and mortality, is characterized by a complex pathophysiology involving neurohormonal activation, metabolic dysregulation, and multiple hormonal deficiency syndrome (MHDS). MHDS is common in HF, affecting up to 90% of patients, and is associated with worse outcomes. This systematic review aims to evaluate the efficacy and safety of testosterone replacement therapy (TRT) in the management of HF.

METHODS

We conducted a comprehensive search of PubMed, the Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) examining TRT in HF patients up to September 15, 2024. Studies were included if they involved human subjects aged 18 or older with a confirmed diagnosis of HF and had a follow-up period of at least 4 weeks. We excluded reviews, animal studies, observational studies, and trials without randomization.

RESULTS

Our search yielded 653 records, of which 12 studies met the inclusion criteria. Key findings include significant improvements in muscle strength and aerobic capacity as well as increases in lean muscle mass and decreases in fat mass in certain trials. Additionally, improvements in insulin sensitivity and shortening of the QT interval were reported. TRT did not consistently affect blood pressure, lipid profiles, or heart rate, nor did it lead to any serious adverse effects.

DISCUSSION

While TRT has demonstrated potential benefits in HF patients, particularly in improving physical function and metabolic profiles, the current evidence is limited by small sample sizes and short follow-up periods. Larger event-driven RCTs evaluating hard endpoints are needed to determine whether TRT should be integrated into standard HF therapies.

Ghrelin: An Emerging Therapy for Heart Failure

OBJECTIVE

Ghrelin is emerging as a promising therapeutic option for heart failure (HF) due to its potent inotropic, anabolic, and cardioprotective properties. This review aims to critically examine the available clinical evidence on ghrelin therapy in HF, while also incorporating key findings from preclinical studies that support its therapeutic potential.

METHODS

A comprehensive search was conducted in PubMed and the Cochrane Library up to September 15, 2024, using the keywords "heart failure" and "ghrelin." From 247 identified records, four randomized controlled trials, one open-label trial, one observational study, and key preclinical studies were included. Two independent authors performed the screening and quality assessment, with any discrepancies resolved through consensus.

RESULTS

Clinical trials investigating ghrelin's acute effects in HF patients have demonstrated significant improvements in cardiac output, ranging from 15% to 30%. Moreover, one study showed that a 3-week course of ghrelin therapy significantly increased maximal oxygen consumption, lean body mass, and grip strength in HF patients. Preclinical studies further support these clinical findings, highlighting additional benefits of ghrelin, including modulation of the autonomic nervous system, promotion of vasodilation, enhancement of endothelial function, prevention of myocardial remodeling, reduction of arrhythmogenic risk, and increased muscle mass in HF models.

CONCLUSIONS

Ghrelin is a promising therapeutic option for HF, particularly as an inotropic agent with multifaceted benefits, including autonomic nervous system modulation, anabolic effects, and metabolic regulation. However, further trials are required to confirm its long-term efficacy and safety and assess whether its benefits can translate into reductions in hard clinical endpoints.

Leptin and heart failure: the chicken or the egg?

Leptin plays a dual role in heart failure (HF), acting as either a primary driver or a secondary phenomenon depending on the HF subtype. In HF with preserved ejection fraction (HFpEF), chronic hyperleptinemia is a primary mediator of disease initiation and progression, closely linked to obesity and metabolic dysfunction. Elevated leptin levels promote systemic inflammation, sympathetic nervous system activation, arterial stiffness, myocardial hypertrophy, fibrosis, and sodium retention, culminating in diastolic dysfunction and elevated ventricular filling pressures. Conversely, in HF with reduced ejection fraction (HFrEF), elevated leptin levels arise as a secondary response to myocardial dysfunction, systemic inflammation, and tissue hypoperfusion. Here, leptin exacerbates cardiac dysfunction by amplifying neurohormonal activation, inflammation, and cardiac remodeling. Understanding these distinct roles has potential therapeutic implications. In HFpEF, interventions such as weight loss, glucagon-like peptide-1 receptor agonists, sodium-glucose cotransporter-2 inhibitors, and mineralocorticoid receptor antagonists can improve symptoms and prognosis, partly by mitigating chronic hyperleptinemia. Furthermore, leptin-specific therapies should be investigated in clinical trials as potential approach in managing cardiometabolic HFpEF. In HFrEF, management focuses on guideline-directed therapies targeting neurohormonal activation-the key mechanism driving disease progression. However, future research should explore whether modulating leptin signaling could provide additional benefits translated in hard clinical endpoints. By framing leptin as the initiator ("chicken") in HFpEF and a consequence ("egg") in HFrEF, this manuscript highlights the need for individualized, integrated treatment strategies. Addressing both metabolic and cardiovascular components could potentially further improve patient outcomes and quality of life.

Cardiovascular-Endocrine-Metabolic Medicine: Proposing a New Clinical Sub-Specialty Amid the Cardiometabolic Pandemic

Cardiovascular-Renal-Hepatic-Metabolic diseases are on the rise worldwide, creating major challenges for patient care and clinical research. Although these conditions share common mechanisms and often respond to similar treatments-such as lifestyle changes and newer cardiometabolic drugs (e.g., SGLT2 inhibitors, GLP-1 receptor agonists)-clinical management remains divided among multiple specialties. Recently proposed curricula in Cardiometabolic Medicine and Preventive Cardiology reflect an effort to address this fragmentation. In addition, recent studies reveal that hormonal deficiencies may increase cardiovascular risk and worsen heart failure, with emerging data showing that correcting these imbalances can improve exercise capacity and possibly reduce major cardiac events. To overcome gaps in care, we propose a new sub-specialty: Cardiovascular-Endocrine-Metabolic Medicine. This approach unifies three main pillars: (1) Lifestyle medicine, emphasizing nutrition, physical activity, and smoking cessation; (2) the Integrated Medical Management of obesity, diabetes, hypertension, dyslipidemia, heart failure with preserved ejection fraction, early-stage kidney disease, metabolic-associated liver disease, and related conditions; and (3) hormonal therapies, focused on optimizing sex hormones and other endocrine pathways to benefit cardiometabolic health. By bridging cardiology, endocrinology, and metabolic medicine, this sub-specialty offers a more seamless framework for patient care, speeds up the adoption of new treatments, and sets the stage for innovative research-all critical steps in addressing the escalating cardiometabolic pandemic.

From Cardiovascular-Kidney-Metabolic Syndrome to Cardiovascular-Renal-Hepatic-Metabolic Syndrome: Proposing an Expanded Framework

Cardiometabolic diseases represent an escalating global health crisis, slowing or even reversing earlier declines in cardiovascular disease (CVD) mortality. Traditionally, conditions such as obesity, type 2 diabetes mellitus (T2DM), atherosclerotic CVD, heart failure (HF), chronic kidney disease (CKD), and metabolic dysfunction-associated steatotic liver disease (MASLD) were managed in isolation. However, emerging evidence reveals that these disorders share overlapping pathophysiological mechanisms and treatment strategies. In 2023, the American Heart Association proposed the Cardiovascular-Kidney-Metabolic (CKM) syndrome, recognizing the interconnected roles of the heart, kidneys, and metabolic system. Yet, this model omits the liver-a critical organ impacted by metabolic dysfunction. MASLD, which can progress to metabolic dysfunction-associated steatohepatitis (MASH), is closely tied to insulin resistance and obesity, contributing directly to cardiovascular and renal impairment. Notably, MASLD is bidirectionally associated with the development and progression of CKM syndrome. As a result, we introduce an expanded framework-the Cardiovascular-Renal-Hepatic-Metabolic (CRHM) syndrome-to more comprehensively capture the broader inter-organ dynamics. We provide guidance for an integrated diagnostic approach aimed at halting progression to advanced stages and preventing further organ damage. In addition, we highlight advances in medical management that target shared pathophysiological pathways, offering benefits across multiple organ systems. Viewing these conditions as an integrated whole, rather than as discrete entities, and incorporating the liver into this framework fosters a more holistic management strategy and offers a promising path to addressing the cardiometabolic pandemic.

Sarcopenia and Cardiogeriatrics: The Links Between Skeletal Muscle Decline and Cardiovascular Aging

Sarcopenia, an age-related decline in skeletal muscle mass, strength, and function, is increasingly recognized as a significant condition in the aging population, particularly among those with cardiovascular diseases (CVD). This review provides a comprehensive synthesis of the interplay between sarcopenia and cardiogeriatrics, emphasizing shared mechanisms such as chronic low-grade inflammation (inflammaging), hormonal dysregulation, oxidative stress, and physical inactivity. Despite advancements in diagnostic frameworks, such as the EWGSOP2 and AWGS definitions, variability in criteria and assessment methods continues to challenge standardization. Key diagnostic tools include dual-energy X-ray absorptiometry (DXA) and bioimpedance analysis (BIA) for muscle mass, alongside functional measures such as grip strength and gait speed. The review highlights the bidirectional relationship between sarcopenia and cardiovascular conditions such as heart failure, aortic stenosis, and atherosclerotic cardiovascular disease, which exacerbate each other through complex pathophysiological mechanisms. Emerging therapeutic strategies targeting the mTOR pathway, NAD+ metabolism, and senescence-related processes offer promise in mitigating sarcopenia's progression. Additionally, integrated interventions combining resistance training, nutritional optimization, and novel anti-aging therapies hold significant potential for improving outcomes. This paper underscores critical gaps in the evidence, including the need for longitudinal studies to establish causality and the validation of advanced therapeutic approaches in clinical settings. Future research should leverage multi-omics technologies and machine learning to identify biomarkers and personalize interventions. Addressing these challenges is essential to reducing sarcopenia's burden and enhancing the quality of life for elderly individuals with comorbid cardiovascular conditions. This synthesis aims to guide future research and promote effective, individualized management strategies.

Integrated Management of Cardiovascular-Renal-Hepatic-Metabolic Syndrome: Expanding Roles of SGLT2is, GLP-1RAs, and GIP/GLP-1RAs

Cardiovascular-Kidney-Metabolic syndrome, introduced by the American Heart Association in 2023, represents a complex and interconnected spectrum of diseases driven by shared pathophysiological mechanisms. However, this framework notably excludes the liver-an organ fundamental to metabolic regulation. Building on this concept, Cardiovascular-Renal-Hepatic-Metabolic (CRHM) syndrome incorporates the liver's pivotal role in this interconnected disease spectrum, particularly through its involvement via metabolic dysfunction-associated steatotic liver disease (MASLD). Despite the increasing prevalence of CRHM syndrome, unified management strategies remain insufficiently explored. This review addresses the following critical question: How can novel anti-diabetic agents, including sodium-glucose cotransporter-2 inhibitors (SGLT2is), glucagon-like peptide-1 receptor agonists (GLP-1RAs), and dual gastric inhibitory polypeptide (GIP)/GLP-1RA, offer an integrated approach to managing CRHM syndrome beyond the boundaries of traditional specialties? By synthesizing evidence from landmark clinical trials, we highlight the paradigm-shifting potential of these therapies. SGLT2is, such as dapagliflozin and empagliflozin, have emerged as cornerstone guideline-directed treatments for heart failure (HF) and chronic kidney disease (CKD), providing benefits that extend beyond glycemic control and are independent of diabetes status. GLP-1RAs, e.g., semaglutide, have transformed obesity management by enabling weight reductions exceeding 15% and improving outcomes in atherosclerotic cardiovascular disease (ASCVD), diabetic CKD, HF, and MASLD. Additionally, tirzepatide, a dual GIP/GLP-1RA, enables unprecedented weight loss (>20%), reduces diabetes risk by over 90%, and improves outcomes in HF with preserved ejection fraction (HFpEF), MASLD, and obstructive sleep apnea. By moving beyond the traditional organ-specific approach, we propose a unified framework that integrates these agents into holistic management strategies for CRHM syndrome. This paradigm shift moves away from fragmented, organ-centric management toward a more unified approach, fostering collaboration across specialties and marking progress in precision cardiometabolic medicine.

Growth Hormone and Heart Failure: Implications for Patient Stratification, Prognosis, and Precision Medicine

Heart failure (HF) remains a major cause of morbidity and mortality worldwide. While standard treatments primarily target neurohormonal pathways, emerging evidence highlights the significant role of hormonal deficiencies, such as impaired growth hormone (GH) signaling, in HF progression and outcomes. GH is crucial for cardiovascular and skeletal muscle function, and its deficiency has been associated with worse prognosis. This review synthesizes recent findings from randomized controlled trials (RCTs) to explore how GH can contribute to personalized care and improve patient stratification in HF. A comprehensive literature review was conducted using PubMed up to 10 October 2024. Search terms included "growth hormone" combined with "heart failure", "HFrEF", "HFpEF", and "HFmrEF." Only placebo-controlled RCTs published in English and involving human subjects were considered. Data on study design, participant characteristics, GH dosing, and key clinical outcomes were systematically extracted and analyzed. Several trials demonstrated that GH therapy can transiently improve left ventricular ejection fraction (LVEF), exercise capacity, and reduce inflammatory markers. For example, one study has reported an increase in LVEF from 32 ± 3.8% to 43.8 ± 4.6% (p = 0.002), following three months of GH therapy in post-MI HF patients. However, benefits diminished after discontinuation. Additional studies have observed sustained improvements in peak oxygen consumption and LVEF over four years, with an additional trend towards hard endpoint improvement. Conversely, some studies showed no significant impact on cardiac function, highlighting heterogeneity in outcomes. As a result, GH therapy holds promise for improving cardiac and functional parameters in HF patients, but evidence remains mixed. Larger, long-term RCTs are needed to confirm its efficacy and safety. Precision medicine approaches and biomarker-driven strategies may optimize patient outcomes and guide clinical practice.

Beyond Calories: Individual Metabolic and Hormonal Adaptations Driving Variability in Weight Management-A State-of-the-Art Narrative Review

The global rise in obesity underscores the need for effective weight management strategies that address individual metabolic and hormonal variability, moving beyond the simplistic "calories in, calories out" model. Body types-ectomorph, mesomorph, and endomorph-provide a framework for understanding the differences in fat storage, muscle development, and energy expenditure, as each type responds uniquely to caloric intake and exercise. Variability in weight outcomes is influenced by factors such as genetic polymorphisms and epigenetic changes in hormonal signaling pathways and metabolic processes, as well as lifestyle factors, including nutrition, exercise, sleep, and stress. These factors impact the magnitude of lipogenesis and myofibrillar protein synthesis during overfeeding, as well as the extent of lipolysis and muscle proteolysis during caloric restriction, through complex mechanisms that involve changes in the resting metabolic rate, metabolic pathways, and hormonal profiles. Precision approaches, such as nutrigenomics, indirect calorimetry, and artificial-intelligence-based strategies, can potentially leverage these insights to create individualized weight management strategies aligned with each person's unique metabolic profile. By addressing these personalized factors, precision nutrition offers a promising pathway to sustainable and effective weight management outcomes. The main objective of this review is to examine the metabolic and hormonal adaptations driving variability in weight management outcomes and explore how precision nutrition can address these challenges through individualized strategies.

Adipokines and Cardiometabolic Heart Failure with Preserved Ejection Fraction: A State-of-the-Art Review

BACKGROUND

Cardiometabolic heart failure with preserved ejection fraction (HFpEF) is largely driven by obesity-related factors, including adipokines and bioactive peptides primarily secreted by the adipose tissue, such as leptin, adiponectin, and resistin. These molecules link metabolic dysregulation to cardiovascular dysfunction, influencing HFpEF progression and patient outcomes Methods: A comprehensive literature search was conducted in PubMed up to 20 November 2024, using keywords and MeSH terms, such as "HFpEF", "adipokines", "leptin", "adiponectin", and "resistin", yielding 723 results. Boolean operators refined the search, and reference lists of key studies were reviewed. After screening for duplicates and irrelevant studies, 103 articles were included, providing data on adipokines' roles in HFpEF pathophysiology, biomarkers, and therapeutic implications.

RESULTS

Both preclinical and clinical studies have demonstrated that adipokines play a role in modulating cardiovascular function, thereby contributing to the development of cardiometabolic HFpEF. Leptin promotes myocardial hypertrophy, fibrosis, endothelial dysfunction, and inflammation, though contradictory evidence suggests potential cardioprotective roles in subgroups like obese African American women. Adiponectin generally offers protective effects but presents a paradox, where elevated levels may correlate with worse outcomes, which may reflect either a compensatory response to cardiac dysfunction or a maladaptive state characterized by adiponectin resistance. Resistin is associated with increased cardiovascular risk through pro-inflammatory and pro-fibrotic effects, though its role in HFpEF requires further clarification. Other adipokines, like retinol-binding protein 4 and omentin-1, have emerged as potential contributors. Despite growing insights, clinical translation remains limited, underscoring a significant gap between experimental evidence and therapeutic application.

CONCLUSIONS

Future research should focus on targeted interventions that modulate adipokine pathways to potentially improve HFpEF outcomes. Innovative treatment strategies addressing underlying metabolic disturbances and adipokine dysregulation are essential for advancing the management of this challenging condition.