Pharmacy Pearl 25 APRIL 2001

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A 38 y/o balding male patient comes into your office for his annual appointment. He's in relatively good health. He's slightly overweight but does not smoke and tries to walk three times a week for exercise. He has no other significant medical conditions but does have a history of cardiovascular disease in his family (father had a heart attack at age 53). His labs are WNL and his blood pressure is normal.

Besides his positive family history, does he have any other CV risk factors?

SELECT  here for discussion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISCUSSION 25 APRIL 2001

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His male gender isn't considered a risk factor since he's not over 45 years of age. He doesn't smoke, doesn't have diabetes, or high blood pressure. Since his labs are WNL, we'd assume his lipid profile (Total CHOL, LDL, HDL) are at his NCEP recommended levels. He's not obese. There are other minor risk factors such as homocystine, etc. that we don't have space to discuss here. One of those other risk factors MAY be male pattern baldness.

In a recent retrospective cohort study of 22,071 physicians published in Archives of Internal Medicine (Arch Int Med 2000;160:165-71) vertex pattern baldness appeared to be a marker for an increased risk of coronary heart disease (CHD) events. This seemed to be more prevalent in male patients with HTN or hypercholesterolemia. This larger study confirmed similar conclusions from three smaller studies - the Framingham Heart Study, NHANES I, and the Copenhagen Heart Study.

The authors hypothesize the following possible reasons for the apparent increased risk. Bald men have elevated androgen levels. Higher concentrations of androgens plus increased androgen receptors in the scalp result in less hair (baldness). In animal models, androgens have been shown to accelerate atherosclerosis by stimulating vascular smooth muscle growth.

Androgens appear to increase platelet aggregation and may exacerbate hypertension in hypertensive rats. This occurs through the increase of mineralocorticoids and retention of sodium. Androgens adversely affect serum lipids. Androgens lower HDL levels, an independent risk factor for CHD.

Although finasteride does block the 5a reductase enzyme, lowering dihydrotestosterone levels and stimulating hair growth, there's no evidence to show that this intervention will prevent or delay CHD. Minimizing the better-known AHA risk factors discussed above is a patient's best bet at this time. Further studies are needed to collaborate these findings and clarify the risks and mechanisms.

References:

- Lotufo PA, et al. Male pattern baldness and coronary heart disease. Arch Int Med 2000;160:165-71.

- Herrera CR, et al. Baldness and coronary heart disease in men from the Framingham heart study. Am J Epidemiol 1995;142:828-33.

- Ford ES, et al. Baldness and ischemic heart disease in a national sample of men. Am J Epidemiol 1996;143:651-7.

- Schnohr P, et al. A case-control study of baldness in relation to myocardial infarction in men. JAMA 1993;143:651-7.

This Pearl is meant for academic and educational purposes only. This Pearl is meant to raise important points regarding the safe and cost-effective pharmacotherapy of patients. It is not meant to be the definitive reference for the treatment or prophylaxis of various diseases. Although every effort is taken to ensure this Pearl is correct and factual, errors may occur. The Pharmacoeconomic Center assumes no liability for incorrect information or harm that may occur from the use of the information included in this Pearl.

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