Cardiovascular Toxicity of Illicit Anabolic-Androgenic Steroid Use

Abstract

Background: Millions of individuals have used illicit anabolic-androgenic steroids (AAS), but the long-term cardiovascular associations of these drugs remain incompletely understood.

Methods: Using a cross-sectional cohort design, we recruited 140 experienced male weightlifters 34 to 54 years of age, comprising 86 men reporting ≥2 years of cumulative lifetime AAS use and 54 nonusing men. Using transthoracic echocardiography and coronary computed tomography angiography, we assessed 3 primary outcome measures: left ventricular (LV) systolic function (left ventricular ejection fraction), LV diastolic function (early relaxation velocity), and coronary atherosclerosis (coronary artery plaque volume).

Results: Compared with nonusers, AAS users demonstrated relatively reduced LV systolic function (mean±SD left ventricular ejection fraction = 52±11% versus 63±8%; P<0.001) and diastolic function (early relaxation velocity = 9.3±2.4 cm/second versus 11.1±2.0 cm/second; P<0.001). Users currently taking AAS at the time of evaluation (N=58) showed significantly reduced LV systolic (left ventricular ejection fraction = 49±10% versus 58±10%; P<0.001) and diastolic function (early relaxation velocity = 8.9±2.4 cm/second versus 10.1±2.4 cm/second; P=0.035) compared with users currently off-drug (N=28). In addition, AAS users demonstrated higher coronary artery plaque volume than nonusers (median [interquartile range] 3 [0, 174] mL³ versus 0 [0, 69] mL³; P=0.012). Lifetime AAS dose was strongly associated with coronary atherosclerotic burden (increase [95% confidence interval] in rank of plaque volume for each 10-year increase in cumulative duration of AAS use: 0.60 SD units [0.16-1.03 SD units]; P=0.008).

Conclusions: Long-term AAS use appears to be associated with myocardial dysfunction and accelerated coronary atherosclerosis. These forms of AAS-associated adverse cardiovascular phenotypes may represent a previously underrecognized public-health problem.

Keywords: anabolic-androgenic steroids; atherosclerosis; cardiology; cardiomyopathy; diastolic dysfunction; men.

Figure 1. Left Ventricular Systolic and Diastolic Function in Anabolic-Androgenic Steroid Users and Comparison Non-Users

Panel A shows boxplots of left ventricular ejection fraction in anabolic-androgenic steroid (AAS) users (N=86), shown as an entire group (left side of figure) and as subgroups of individuals who were on-drug (N=58) and off-drug (N=28) at the time of evaluation (middle of figure). Non-users (N=54) appear on the right. On this variable, the estimated mean difference (95% confidence interval) between on-drug AAS users and off-drug AAS users, adjusted for covariates as described in the text, is −9.5% (−13.8% to −5.2%); P<0.001; for on-drug AAS users versus non-users, the difference is −13.6% (−17.3% to −9.8%); P<0.001; and for off-drug AAS users versus non-users, the difference is −4.1% (−8.6% to 0.3%); P=0.072. Panel B shows left ventricular early relaxation velocity in the same 4 groups. On this variable, the mean difference between on-drug AAS users and off-drug AAS users is −1.1 (−2.1 to −0.1) cm/s, P=0.035; for on-drug AAS users versus non-users, the difference is −2.2 (−3.1 to −1.4) cm/s, P<0.001; and for off-drug AAS users versus non-users, the difference is −1.1 (−2.2 to −0.1) cm/s; P=0.035.

Figure 2. Distribution of Computed Tomography Coronary Angiography Measures in Anabolic-Androgenic Steroid Users and Non-Users

Histograms displaying distribution of coronary artery plaque volume, degree of stenosis for most severe stenosis, number of diseased coronary artery segments, and coronary artery calcium for anabolic-androgenic steroid (AAS) users (N=84) and non-users (N=53). Note that the histograms for plaque volume and calcium score include for men with imputed values, as described in the footnote to Table 3.

Figure 3. Relationship between Coronary Artery Plaque Volume and Cumulative Lifetime Duration of Anabolic-Androgenic Steroid Exposure

Scatter plot displaying coronary artery plaque volume and cumulative years of lifetime anabolic-androgenic steroid (AAS) exposure, with a median spline (red line) fitted to the data to aid in the visualization of the relationship between these variables. Because of the highly right-skewed distributions, the data are presented on a transformed scale (square root transformation for coronary artery plaque volume; logarithmic transformation for cumulative years of AAS use).