Could a prostate drug improve STEMI outcomes?

Clinical takeaway: Among men presenting with PCI-treated ST-elevation myocardial infarction (STEMI), pre-existing use of a 5-alpha reductase inhibitor (5-ARI) was associated with fewer severe early complications, raising the possibility that androgen modulation may influence acute post-MI outcomes. However, the findings are observational and should not change prescribing decisions pending further study.

Men tend to experience larger infarct sizes and worse short-term outcomes after STEMI than women. Previous translational research has suggested that testosterone may amplify inflammatory responses and myocardial injury during acute MI, prompting interest in whether drugs that reduce androgen activity, such as the 5-alpha reductase inhibitors finasteride and dutasteride, could mitigate post-MI complications.

In this nationwide Swedish cohort study, investigators analyzed more than 40,000 men aged 35 to 84 years with first-time STEMI treated with percutaneous coronary intervention (PCI). After propensity-score matching, 1,305 men taking a 5-ARI for benign prostatic hyperplasia were compared with 6,463 similar untreated controls, while 358 men receiving androgen deprivation therapy (ADT) were matched to 1,774 controls.

The primary endpoint was a composite of 30-day mortality or major in-hospital complications, including cardiac arrest, cardiogenic shock, advanced atrioventricular block, new atrial fibrillation/flutter, severe left ventricular dysfunction, or mechanical complications. Severe complications occurred in 20.8% of men taking a 5-ARI versus 24.3% of matched controls, representing about a 20% lower adjusted likelihood of experiencing the composite outcome. Rates of several individual complications, including cardiac arrest, cardiogenic shock, severe LV dysfunction, and new atrial fibrillation/flutter, also trended lower among 5-ARI users.

In contrast, no significant reduction in severe complications was observed among men receiving ADT. Sensitivity analyses produced similar results, supporting the robustness of the 5-ARI findings. The authors emphasized that residual confounding cannot be excluded and that causality cannot be established from this observational study.

“As with all observational studies, we cannot infer causality from observed associations,” the authors noted, adding that the findings “warrant further research into the role of androgens and drugs that affect androgen levels in the acute phase of STEMI.”

Source: Colldén H, et al. (2026 Aug 25) JAMA Netw Open. Androgen-Modulating Drugs and Severe Complications After ST-Elevation Myocardial Infarction