Risk of myocardial infarction in the pathophysiology and treatment of prostatic diseases

Benign prostatic hyperplasia (BPH) and prostate cancer (PC) have shown an increased prevalence among elderly population in the last ten years leading to a significant deterioration in the quality of life and life span. BPH is a non-malignant adenofibromyomatous overgrowth of the periurethral portion of prostate gland that becomes clinically manifest through bladder outlet obstruction symptoms. PC is the most common malignancy in men and often shows an adenocarcinoma histology with symptoms such as hematuria and obstruct urine flow. Pharmacological treatment of BPH includes α-adrenergic blockers and PDE-5 inhibitors though surgery is necessary if medical therapy fails or obstructive symptoms are impressive. Transurethral resection of the prostate (TURP) is the gold standard surgery for PBH; however open prostatectomy could also be considered as an option. PC therapy is determined by PSA level, grade and stage of tumor, age and comorbidity. Generally, surgery or radiation therapy are preferred for localized cancer while hormonal therapy, radiation therapy or chemotherapy are utilized for symptomatic, advanced, and metastatic PC. Particularly, in patients with a locally advanced tumor or metastases, androgen deprivation therapy (ADT) by bilateral orchiectomy or medical therapy with gonadotropin-releasing hormone (GnRH) agonists and antagonist are commonly utilized. Recently, several studies exploring the relationship between cardiovascular (CV) risk and prostatic diseases have been published. In fact, there are some factors involved in the pathophysiology and treatment of prostatic diseases that may influence the establishment and progression of myocardial infarction (MI) in elderly patients with comorbidities. First of all, perioperative and postoperative urological surgery are associated with cardiological complications as MI. Indeed, some studies showed an increase in MIrelated mortality after TURP vs open prostatectomy. Furthermore, ADT (GnRH agonists and orchiectomy) induces a status of hypogonadism, which is related to adverse events as metabolic syndrome, diabetes and CV diseases. In fact, it has been demonstrated an increased risk of a CV events (coronary heart disease, MI and cardiac death) in PC patients treated with GnRH agonists. Besides, 6-months therapy with GnRH agonists is related to an earlier timing of fatal MI in elderly patients while GnRH antagonists administration decreases cardiac events (ischemic cerebrovascular diseases, MI, and other ischemic heart disease) in patients with preexisting CV disease during the first year of treatment compared to GnRH agonists. Therefore, in this chapter we will analyze in detail the aforementioned data of the literature and we will discuss the CV, hormonal and metabolic factors involved in the development either of MI than prostatic disease. In particular, establishment of metabolic syndrome increases the estrogen-to-androgen ratio leading to sympathetic overactivity and influences the progression of BPH. Subsequently we will evaluate the surgical elements and the factors related to medical therapy for prostatic disease that are connected to myocardial damage. Finally we will emphasize that in patients with prostatic disease is very important to evaluate pre-existing CV diseases and myocardial function and to strictly recommend a healthy lifestyle that includes a moderate and adequate exercise training associated to a balanced diet.