Young Men Who Take Steroids Have Impaired Coronary Flow, Even After Quitting

Young men who use anabolic-androgenic steroids, or those who’ve used them in the past, are more likely to have reduced myocardial flow reserve than those who’ve never taken the drugs, according to Danish data.

The findings, researchers say, suggest that “supraphysiologic doses of testosterone and synthetic steroids could have adverse impacts in coronary microcirculation.” Led by Yeliz Bulut, MD (Copenhagen University Hospital-Rigshospitalet, Denmark), the study was published Monday in JAMA Network Open.

Senior investigator Caroline Kistorp, MD, PhD (Copenhagen University Hospital-Rigshospitalet), told TCTMD that her interest in the topic was borne out of her own clinical experience as an endocrinologist seeing men present with steroid side effects, as well as growing awareness of the adverse effects these performance-enhancing drugs have on the cardiovascular system.

“Every time we looked into the heart, we found something new,” Kistorp said, citing LV dysfunction and hypertrophy as well as increased LV mass.

With the latest study, what’s especially worrisome is that participants were, on average, in their mid-30s but already had signs of damage after steroid use, she noted. Most of the patients she sees have heard anecdotally about “friends who might have some problems with their heart, but they’re all young men: they think, ‘This is never going to happen to me.’”

Also concerning, it’s possible “that some of the changes in the cardiac structure and function may be irreversible, since we found them years after they stopped,” said Kistorp. “We can’t find any pattern that after 3 years or something like that, then you’re [in the] clear.”

Aaron L. Baggish, MD (Université de Lausanne/Centre Hospitalier Universitaire Vaudois, Switzerland), whose 2017 Circulation paper linked use of anabolic-androgenic steroids among male weightlifters to myocardial dysfunction and accelerated coronary atherosclerosis, commented on the new findings for TCTMD.

The Danish study “offers yet another part of the cardiovascular system—in this case it’s the microvasculature—which seemed to be responsive in a negative way to anabolic steroid use,” Baggish said, adding that the method they used to look at coronary microcirculation is the gold standard. One limitation, he added, is that steroid use is quantified by duration of use and abstinence, not dose. Another approach would be to estimate testosterone equivalents, thereby capturing how much drug is actually used.

That said, it’s interesting that “use over longer periods of time, which probably means more exposure to more drug, seems to have a more lasting effect on the coronary microvasculature,” said Baggish. Whether the damage is permanent is not yet known, he specified, though it’s possible that the impact is twofold, with steroids causing both acute toxicity and longer-term pathology.

Baggish described anabolic-androgenic steroids as a “huge public health issue, and that is despite the fact that we continue to learn more and more scientifically about the evils of these drugs.

“To be clear, this is no longer a story of elite athletes,” he continued. “This is a story of . . . typically community-dwelling men in their 30s, 40s, and 50s who simply want to or need to get bigger and feel bigger. Globally, there are millions of men that are subjecting themselves to this, because it’s so easy to get steroids and the sad truth is that they work. [Plus,] it’s really difficult for some men, once they get started, to stop.”

Every time we looked into the heart, we found something new. Caroline Kistorp

The study included 90 men (mean age 35.1 years) recruited via gyms, social media, word of mouth, and endocrine outpatient clinics in the Copenhagen area: 33 with current use of anabolic-androgenic steroids, 31 with former use, and 27 controls. For those who had quit, the time since steroid cessation was a geometric mean of 1.5 years, with 58.1% quitting more than a year earlier.

Systolic blood pressure and LDL levels were higher, and body fat was lower, in current steroid users than in former users or controls. Participants who formerly used anabolic-androgenic steroids were more likely to have previously used other illicit drugs than were current users or controls.

Bulut and colleagues used ⁸²Rb positron emission tomography/computed tomography (PET/CT) to measure myocardial flow reserve, with levels below 2.0 mL/g/min considered clinically relevant.

Among current steroid users, 18.8% had clinically impaired myocardial flow reserve, as did 3.2% of former users. None of the controls showed impairment (P= 0.02). Subclinically impaired myocardial flow reserve—levels below 2.5 mL/g/min—was seen in 28.1% of individuals currently on steroids, 25.8% of those who had quit, and 3.7% of controls (P = 0.02).

In multivariable logistic regression analysis, accumulated exposure was linked to higher risk of impaired flow reserve. With every doubling of weekly duration in anabolic-androgenic steroid use, the risk of having myocardial flow reserve below 2.5 mL/g/min also doubled (OR 2.1; 95% CI 1.03-4.35).

“Early and persistent impaired myocardial microcirculation could be of clinical importance and a potential underlying mechanism of frequent and early cardiac disease among individuals with anabolic-androgenic steroid use and a future potential target for intervention,” the researchers conclude.

Next up, said Kistorp, the investigators plan to do a similar study: this time on women, who make up a minority of steroid users.

As for how clinicians should apply these findings, Kistorp said it makes most sense to check into steroid use when patients have high cholesterol or other risk factors without an obvious cause. At her center, she said, cardiologists first “do the more classical workup, and if they can’t find anything, then they start asking if you have been using steroids.”

If [clinicians] don’t ask about steroid use either prior or active, they will never be told, and they will be surprised how often they’ll learn about it if they ask. Aaron L. Baggish

Baggish said it’s too soon to draw firm conclusions from this one study but generally speaking, he agreed that when a young male patient presents with an unexplained cardiovascular condition, physicians should bring up the topic. “If they don’t ask about steroid use either prior or active, they will never be told, and they will be surprised how often they’ll learn about it if they ask,” he said.

This knowledge might not only guide treatment but also encourage patients to quit steroids, said Baggish. “I find in my practice that many anabolic steroid users have no idea that these drugs can cause heart disease. When they’re confronted with a new diagnosis and they reconcile with the fact that they may have done this to themselves, there can be a pretty strong motivation to stop using steroids. If you don’t ask and don’t help the patient make that link, you don’t give them the opportunity to make the wise choice, which is to drop the drugs.”