Illicit Anabolic Steroid Use and Cardiovascular Status in Men and Women

Abstract

Importance: The illicit use of anabolic androgenic steroids (AAS) is common among recreational athletes, yet studies on adverse cardiovascular outcomes, especially in female AAS users, are sparse.

Objective: To assess cardiovascular status in Danish male and female recreational athletes using AAS compared with not using AAS.

Design, setting, and participants: This cross-sectional study in a single center in Denmark included recreational athletes aged 18 years or older who were active AAS users, previous users (defined as those who discontinued AAS use at least 3 months prior to the study), or nonusers, all recruited from fitness centers between March and December 2022.

Exposure: Cumulative lifetime use of AAS.

Main outcomes and measures: Presence of atherosclerosis (carotid, femoral, and coronary artery plaques) and cardiac function assessed by echocardiography. Linear regression was used to estimate regression coefficients for echocardiographic characteristics and logistic regression to estimate odds ratios (ORs) for carotid and femoral plaques, coronary artery calcium (CAC) scores, and coronary noncalcified plaques (NCPs).

Results: Of 164 participants, 80 (48.8%) were active AAS users (median age, 35 [IQR, 30-43] years; 61 men [76.2%]), 26 (15.9%) were previous users (median age, 36 [IQR, 28-51] years; 18 men [69.2%]), and 58 (35.4%) were nonusers (median age, 40 [IQR, 31-46] years; 42 men [72.4%]). Median cumulative lifetime AAS use was 2.2 (IQR, 1.2-7.2) years for active and 2.2 (IQR, 1.0-5.5) years for previous users. No group differences were observed when comparing the number of participants with femoral (active users, 15 [19.7%]; previous users, 5 [19.2%]; nonusers, 11 [20.8%]; P = .89) or carotid (active users, 24 [31.2%]; previous users, 12 [46.2%]; nonusers, 13 [24.1%]; P = .47) artery plaques or CAC scores (median score was 0 across all groups with range of 0-228 for active users, 0-800 for previous users, and 0-163 for nonusers; P = .36), whereas a statistically significant difference in the prevalence of coronary NCPs was found between active users (19 [23.8%]) and nonusers (6 [10.3%]) (P = .03). However, in confounder-adjusted logistic regression, longer cumulative lifetime AAS use was associated with higher odds of a positive CAC score (OR, 1.23; 95% CI, 1.09-1.39; P = .001) and presence of coronary NCPs (OR, 1.17; 95% CI, 1.05-1.30; P = .004). AAS use exceeding 5 years was associated with greater severity of calcifications (n = 94; χ2 = 9.78; P = .04). Echocardiography showed that cumulative AAS use was associated with worse left ventricular (regression coefficient: 0.08; 95% CI, 0.03-0.12; P = .002) and right ventricular (0.08; 95% CI, 0.03-0.13; P = .001) global longitudinal strain. Nearly all athletes (35 of 36) with more than 5 years of cumulative AAS use had ventricular mass greater than and left ventricular ejection fraction below the median of the normal range.

Conclusions and relevance: In this cross-sectional study, cumulative lifetime AAS exposure was associated with adverse cardiovascular findings and impaired ventricular function in both sexes, and athletes with AAS exposure exceeding 5 years showed more severe calcification. The findings support measures to prevent AAS use by both men and women in recreational sports.

Figure 1.. Coronary Artery Atherosclerosis and Calcified Plaque Severity by Lifetime Duration of Anabolic Androgenic Steroids (AAS) Use

A, B, Logistic regression analysis compared the presence (coronary artery calcification [CAC] score >0) vs absence (CAC score = 0) of coronary artery atherosclerosis in previous and active AAS users (n = 106) vs nonusers (n = 58), stratified by cumulative lifetime duration of AAS intake. The fully adjusted model was adjusted for age, sex, body fat percentage, family history of coronary artery disease, blood pressure, total cholesterol, use of recreational drugs, tobacco smoking status, alcohol consumption, and hours of hard exercise and strength training per week. C, Thirty-six participants had AAS intake of more than 5 years and 58 were nonusers (n = 94; χ² = 9.78; P = .04). OR indicates odds ratio.

Figure 2.. Associations Between Echocardiographic Parameters and Lifetime Duration of AAS Use

The dotted blue lines represent the median of the normal range. AAS indicates androgenic anabolic steroids; E, early mitral peak velocity; E′, left ventricular relaxation; LVEF, left ventricular ejection fraction.