How to cite: Crawford ED and Patel SA. “ADT and Cardiovascular Risk: Insights from the REVELUTION Study”. Grand Rounds in Urology. November 2025. Accessed Apr 2026. https://grandroundsinurology.com/adt-and-cardiovascular-risk-insights-from-the-revelution-study/
Summary
E. David Crawford, MD, Editor-in-Chief of Grand Rounds in Urology and Professor of Urology at the University of California, San Diego, San Diego, California, introduces Sagar A. Patel, MD, Associate Professor, Winship Cancer Institute, Emory University, Atlanta, Georgia. Dr. Patel describes findings from the REVELUTION trial, a randomized study investigating whether the cardiovascular risk associated with androgen deprivation therapy (ADT) differs by drug pathway. He highlights longstanding uncertainty regarding the etiology of cardiovascular events observed in patients receiving these therapies.
Dr. Patel explains that prior studies have produced conflicting results regarding differences between gonadotropin-releasing hormone agonists and antagonists. The HERO study identified a signal suggesting fewer major adverse cardiovascular events with the antagonist relugolix compared with the agonist leuprolide. Building on this observation, the REVELUTION trial evaluates whether these differences are mediated through atherosclerotic processes.
The trial uses coronary computed tomography angiography to directly measure coronary plaque burden before and after treatment initiation. Results demonstrate greater progression of coronary plaque, particularly noncalcified plaque, in patients receiving a gonadotropin-releasing hormone agonist compared with those receiving an antagonist. Noncalcified plaque is emphasized as a vulnerable subtype associated with plaque instability and cardiovascular events.
Dr. Patel describes a proposed biologic mechanism involving immune activation through peripheral receptors and potential contributions from follicle-stimulating hormone signaling. This pathway may promote macrophage activation and plaque progression in response to agonist therapy, whereas antagonists may mitigate this effect.
Dr. Patel underscores the importance of cardiovascular risk awareness and risk stratification in patients receiving ADT. He acknowledges that coronary imaging is not broadly practical, and emphasizes attention to baseline risk factors and collaboration with cardiology. Future directions include the REVELUTION 2 study, which will evaluate plaque progression with combination therapy.
ABOUT THE AUTHOR
Sagar A. Patel, MD, is a board-certified Radiation Oncologist and the Director of Brachytherapy in the Department of Radiation Oncology at the Winship Cancer Institute of Emory University in Atlanta, Georgia. He is also an Associate Professor in the Departments of Radiation Oncology and Urology at the Emory University School of Medicine. He specializes in the treatment of genitourinary cancers, including prostate, bladder and kidney cancer. He received a Master of Science in Clinical Research at Emory University and completed his medical degree at Harvard Medical School. He also completed residency training at the Harvard Radiation Oncology Program and fellowship training in Prostate Brachytherapy at UCLA.
Researcher-physician E. David Crawford, MD, has devoted his medical career to educating the public about men's health issues and finding effective techniques and procedures to address prostate cancer, the most common malignancy affecting men in the United States. He is currently a Professor of Urology and Jack A. Vickers Director of Prostate Research at the University of California, San Diego. Dr. Crawford earned his MD from the University of Cincinnati and his postgraduate training, which included an internship and residency in Urology, at the Good Samaritan Hospital in Cincinnati, Ohio. He subsequently completed a fellowship in Genitourinary Cancer at the University of California, Los Angeles. Dr. Crawford is an internationally-recognized expert in benign prostate hypertrophy, urologic cancers, and, in particular, prostate cancer. He has conducted research in the treatment of advanced bladder cancer, metastatic adenocarcinoma of the prostate, hormone-refractory prostate cancer, and other areas of urological infections and malignancies.
