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Inflammation plays a central pathogenic role in the initiation and progression of coronary atheroma and its clinical consequences. Cytokines are the mediators of cellular inflammation and promote local inflammation in the arterial wall, which may lead to vascular smooth muscle apoptosis, degradation of the fibrin cap and plaque rupture. Platelet adhesion and thrombus formation then occur, resulting clinically in unstable angina or myocardial infarction. Recent studies have suggested that cytokines are pathogenic, contributing directly to the disease process. 'Anti-cytokine' therapy may, therefore, be of benefit in preventing or slowing the progression of cardiovascular disease. Both oestrogens and testosterone have been shown to have immune-modulating effects; testosterone in particular appears to suppress activation of pro-inflammatory cytokines. Men with low testosterone levels are at increased risk of coronary artery disease. An anti-inflammatory effect of normal physiological levels of sex hormones may, therefore, be important in atheroprotection. In this Article, we discuss some of the mechanisms involved in atherosclerotic coronary artery disease and the putative link between testosterone deficiency and atheroma formation. We present the hypothesis that the immune-modulating properties of testosterone may be important in inhibiting atheroma formation and progression to acute coronary syndrome.

Testosterone-induced vasodilatation is proposed to contribute to the beneficial effects associated with testosterone replacement therapy in men with cardiovascular disease, and is postulated to occur via either direct calcium channel blockade, or through potassium channel activation via increased production of cyclic nucleotides. We utilised flow cytometry to investigate whether testosterone inhibits the increase in cellular fluorescence induced by prostaglandin F(2alpha) in A7r5 smooth muscle cells loaded with the calcium fluorescent probe indo-1-AM, and to study the cellular mechanisms involved. Two-minute incubation with testosterone (1 microM) significantly inhibited the change in cellular fluorescence in response to prostaglandin F(2alpha) (10 microM) (3.6+/-0.6 vs 7.6+/-1.0 arbitrary units, P=0.001). The change in cellular fluorescence in response to prostaglandin F(2alpha) (10 microM) was also significantly attenuated in the absence of extracellular calcium (3.6+/-0.3 vs 15.6+/-0.7 arbitrary units, P=0.0000002), and by a 2-min incubation with the store-operated calcium channel blocker SK&F 96365 (50 microM) (4.7+/-0.8 vs 8.1+/-0.4 arbitrary units, P=0.003). The response was insensitive to similar incubation with the voltage-operated calcium channel blockers verapamil (10 microM) (12.6+/-1.2 vs 11.9+/-0.2 arbitrary units, P=0.7) or nifedipine (10 microM) (13.9+/-1.3 vs 13.3+/-0.5 arbitrary units, P=0.7). Forskolin (1 microM) and sodium nitroprusside (100 microM) significantly increased the cellular concentration of cyclic adenosine monophosphate and cyclic guanosine monophosphate respectively, but testosterone (100 nM-100 microM) had no effect. These data indicate that the increase in intracellular calcium in response to prostaglandin F(2alpha) occurs primarily via extracellular calcium entry through store-operated calcium channels. Testosterone inhibits the response, suggesting an antagonistic action upon these channels.