Anabolic Steroid Use Linked With Myocardial Dysfunction and Accelerated Atherosclerosis

Chronic use of anabolic-androgenic steroids among male weightlifters leads to myocardial dysfunction and accelerated coronary atherosclerosis, according to a new study published online ahead of print in Circulation. Experts warn that these findings may have widespread implications for public health, as anabolic steroids are commonly abused, even outside athletic settings.

To TCTMD, lead investigator Aaron L. Baggish, MD (Massachusetts General Hospital, Boston, MA), said there is a “growing but inconclusive” body of evidence, mainly case series and small observational cohorts, suggesting a link between steroid use and cardiovascular health. The Cardiovascular Performance Program at Massachusetts General Hospital also attracts athletes with heart disease, including men severely damaged heart muscle and coronary disease that is otherwise unexplained aside from past steroid use.

“Our finding of impaired cardiac muscle function was largely confirmatory, but the magnitude of dysfunction was higher than expected, and thus a surprise,” reported Baggish. “This is the first report documenting accelerated coronary artery disease among prior anabolic steroid users.”

Impaired LVEF and Greater Plaque Burden

In their study, the researchers used transthoracic echocardiography and CT angiography to compare cardiovascular features of 86 experienced male weightlifters who reported two or more years of cumulative lifetime use of anabolic-androgenic steroids with those of 54 male weightlifters with no history of anabolic-androgenic steroid use. All participants were 34 to 54 years of age.

Anabolic steroid users demonstrated reduced left ventricular systolic function and diastolic function as well as higher coronary artery plaque volume compared with nonusers.

Outcomes by Anabolic-Androgenic Steroid Use

The 58 weightlifters who were currently still using anabolic steroids had reduced ventricular systolic and diastolic function compared with the 28 weightlifters who had used them in the past but were currently off the drugs.

Lifetime anabolic steroid dose was strongly associated with coronary atherosclerotic burden, with an increase in rank of plaque volume for each 10-year increase in cumulative duration of steroid use of 0.60 SD units (95% CI 0.16-1.03, P = 0.008).

Considerable Public Health Burden

The findings are alarming because anabolic steroid use is far from being confined to elite athletes, Richard C. Becker, MD (University of Cincinnati College of Medicine, Cincinnati, OH), told TCTMD. Becker, a spokesperson for the American Heart Association, said it is estimated “that as many as 1% of all males between the ages of 15 and 30 use or have used anabolic steroids, and the majority of them are not athletes.”

In this study, the average age that the men started using the steroids was 23, and the cardiovascular effects were evident within 2 years. The findings suggest that these men may be accelerating the development of myocardial dysfunction and atherosclerotic plaque by as much 20 years, and the effects may be long-lasting, even after anabolic steroid use is discontinued.

Both Baggish and Becker recommended that cardiologists inquire about current or former use of anabolic steroid use among their newly diagnosed patients with CVD. They also said that use of these agents should be considered a risk factor much like smoking, dyslipidemia, and diabetes. Becker noted that anabolic steroid use can also contribute to certain risk factors for CVD, notably dyslipidemia and hypertension.

“For me as cardiologist . . . it sends a powerful message,” said Becker. “If your perception is [that] it’s only competitive athletes who might use anabolic steroids, you are missing literally millions of individuals. So, you have to ask about it.”

Some men may choose to continue to use despite the potential risks, but physicians should still engage them in a frank discussion about what this might mean for their heart health, said Becker. While it remains unclear if the risks of anabolic steroid use can be effectively minimized, it would be sensible for these individuals to be particularly careful about managing other cardiovascular risk factors, he noted.

According to Baggish, “the largest unanswered question is how our data will translate into long-term hard clinical endpoints like mortality. Large-scale studies with longitudinal follow-up will be required to address this important area of uncertainty.” Becker added that other unanswered questions are how common anabolic steroid use is in women and whether it has similar cardiovascular effects in them.