Anabolic steroid misuse is an important reversible cause of cardiomyopathy: a case report

Abstract

Background: Anabolic steroid misuse is very common and has been linked to the development of a severe cardiomyopathy, arrhythmias, and sudden death.

Case summary: A 46-year-old miner presented to hospital with subacute dyspnoea and palpitations. Investigations revealed atrial fibrillation and a severe dilated cardiomyopathy with left ventricular ejection fraction of 12%. The patient had a history of longstanding exogenous testosterone administration. Haematological investigations demonstrated a marked polycythaemia, with haematocrit of 0.60 L/L (normal 0.40-0.54 L/L). Hormonal investigations revealed an elevated testosterone level of 46.4 nmol/L (normal 8.0-30.0 nmol/L) and suppressed luteinizing and follicle-stimulating hormones, consistent with excess testosterone use. The patient was referred to the endocrinology specialty team for support with ceasing excess testosterone use, while commencing guideline-directed heart failure therapy. At 6 months of follow-up, the patient's left ventricular ejection fraction had normalized and he was asymptomatic. Biochemical indicators of testosterone excess had also normalized.

Discussion: Anabolic steroids are widely misused, particularly among young and middle-aged males. Cardiovascular complications include a potentially reversible severe cardiomyopathy, accelerated coronary disease, dyslipidaemia, arrhythmias, and sudden death. It is important to identify a history of anabolic steroid misuse when investigating cardiomyopathy and be alert for indicators such as polycythaemia. Cessation of anabolic steroid misuse may lead to complete reversal of cardiomyopathy but should be undertaken in close partnership with the patient and endocrinologists.

Keywords: Anabolic steroids; Cardiomyopathy; Case report; Heart failure; Performance-enhancing drugs; Testosterone.

Figure 1

A 12-lead electrocardiogram on initial presentation showing atrial fibrillation.

Figure 2

Echocardiographic strain images. (A) During anabolic steroid misuse and (B) 6 months after cessation and with the guideline-directed medical therapy. GLPSS, global longitudinal peak systolic strain, normal value −18% to −22%.

Figure 3

Sample of four-chamber images from cardiac magnetic resonance imaging, including phase-sensitive inversion recovery sequences, demonstrate a moderately dilated left ventricle with no evidence of inflammation or late gadolinium enhancement.

Figure 4

Interplay of anabolic steroids with cardiovascular risk factors.