Is TRT safe from a cardiovascular standpoint — what does the research say?

The TRAVERSE trial (Lincoff et al., NEJM, 2023), the largest RCT of TRT in hypogonadal men with cardiovascular risk factors (5,246 men, 33 months), found TRT non-inferior to placebo for major adverse cardiovascular events (MACE: heart attack, stroke, cardiovascular death), but found a 16% higher rate of atrial fibrillation and a 2.3-fold higher rate of pulmonary embolism in the TRT group, establishing that TRT requires individualized cardiovascular risk assessment, not population-wide prescription or telehealth dispensing without evaluation (Lincoff et al., NEJM, 2023).

The pre-TRAVERSE data was mixed: some observational studies suggested TRT increased cardiovascular risk, others showed benefit. TRAVERSE resolved the MACE controversy (no increased risk for heart attack or stroke in hypogonadal men with established cardiovascular risk). What TRAVERSE confirmed as concerns: atrial fibrillation (men with existing AF history, structural heart disease, or at high AF risk should approach TRT with caution) and pulmonary embolism (men with hypercoagulable states, prior VTE, or who will develop polycythemia on TRT are at meaningful PE risk).

Honesty Scale: Solid (1) for TRAVERSE's MACE non-inferiority finding. Solid (1) for the atrial fibrillation and PE risk signals.

What to do: Before TRT, ensure cardiovascular pre-screening including: ECG (looking for AF risk markers), blood pressure assessment, hematocrit/CBC (polycythemia risk), and history of any prior thromboembolic event. A cardiologist or internist with cardiovascular risk assessment capacity should be part of your TRT clinical team, not just a telehealth prescriber.

For the full picture, read The Testosterone/TRT Deep Dive