Anabolic-Androgenic Steroid Abuse Causes Cardiac Dysfunction

Abstract

This article aims to review available literature evidence about the harmful effects of long-term anabolic-androgenic steroid (AAS) abuse on the heart. A review of 11 existing literature articles regarding this association has been used in the development of this review article. There is increasing medical literature documentation of the eventual harmful effect of AAS misuse or abuse on the heart. Individuals who misuse these steroids are susceptible to significant debilitation and loss of productive person-hours, and in severe cases, it can lead to death. Raising awareness about this potentially deleterious effect of anabolic steroids is crucial to prevent its misuse or abuse.

Introduction/Epidemiological Perspective

An increasingly demonstrable harmful effect of anabolic-androgenic steroid (AAS) abuse on the heart is being noted in the literature. Educating the public about this then becomes a necessity. AASs are misused for performance and aesthetic purposes by athletes and bodybuilders. Some people abuse AAS for leisure. The untoward side effects of AAS toxicity on the heart could be increased when used in combination with other abused substances. The flow of these abused substances is from health care professionals to those who abuse these substances in the community (Melnik, 2009). Another way people get these unauthorized products is via the internet. Gagnon et al. (2022) noted on a global view that about 3 out of 100 persons in their lifetime would have abused AAS. This abuse problem is commoner under the productive age of 50 years and more than 95% of AAS abuse problems are in males (Kanayama et al., 2018).

Disease Process and Impact of AAS Toxicity on the Heart

Exposure to higher-than-normal doses of these steroids can predispose to a condition where the heart becomes enlarged and weakened or the heart muscle becoming thickened and stiff or a mix of the two. It can also result in a condition where plaques build up in arteries of the body, narrowing and hardening them (a condition called atherosclerosis). When atherosclerosis becomes severe, it can cause significant damage to the heart and to the blood vessels.

An unreversed heart failure after 6 months of treatment in a 31-year-old male who had abused AAS for 12 years and growth hormone for 1 year was noted in a case report. The patient had quit the substance abuse for a year prior to presentation to the hospital. The suggestion that the damage to heart muscles may be irreversible from prolonged duration of AAS abuse was made in the publication. It was also noted that this could be worse in the presence of other potentiating toxic agents (e.g., growth hormone misuse), as well as hard gym or exercise sessions (Angelini et al., 2019). Another case report however reported a gradual reversal of an abnormal heart affectation after a 9-month follow-up period in a 47-year-old non-athletic female who had abused AAS for social reasons and had initially presented with heart failure features (Gul & Shahid, 2022).

Apart from AASs, other commonly abused substances with the potential of causing impairment of the heart’s function include cocaine, alcohol, tobacco, cannabis, and methamphetamine. There could be an additive or multiplier effect on the number of these substances abused together (Gagnon et al., 2022). In another case report about a 31-year-old male who abused AAS for more than 2 years and abused mephentermine for 3 months, he had a hospital admission for a new diagnosis of heart failure. A special test to look at the patient’s heart (echocardiogram) revealed the left side of the heart was functionally impaired. They also found a blood clot in that area. While the patient was in the hospital, he had a type of stroke caused by blood clot dislodged from the heart to the brain. The patient’s heart function improved after he stopped the use of mephentermine for 2 months, but then got worse again when he started taking it again after 3 months (Singal et al., 2021).

A late effect of AAS abuse in a 73-year-old ex-Olympic athlete who had quit using AAS for about three decades was described in a case report in 2018. The patient had abused AAS for a period of about 20 years in his active sporting years. He presented to the hospital with an abnormal fast heart rhythm and, on assessment, was found to have a thickened left heart region that had problem with contracting to push blood out, as well as with relaxation to receive blood in. It was concluded in the publication that there could be long-term consequences on the heart in those who abuse anabolic steroids many years after discontinuing them (Ha et al., 2018).

A study reviewing the toxic effect of high doses of nandrolone on the heart of young rabbits was published in 2015. The study found that the group of rabbits that were administered with nandrolone (either under their skin or into their muscles) had a worse heart muscle performance index compared to the group that was not injected with nandrolone. Among the rabbits injected with nandrolone, although their heart’s contractile function was preserved, there was a problem with relaxation due to their thickened heart musculature. Their study also noted that the administration of nandrolone under the skin had a worse effect on the heart and the body’s blood vessels than administering nandrolone deep into muscles (Vasilaki et al., 2016).

A study by Bulut et al. (2023) showed that people who have used AASs in the past might have problems with the small blood vessels in their heart. The study compared people who currently or formerly used AAS to those who did not and found that the former group had a decrease in the heart muscle blood flow reserve, as measured by a type of imaging test-positron emission tomogrpahy-computerized tomography using Rubidium Rb-82 injection (PET/CT Rb-82). This suggests that the heart’s small blood vessels may not work as well in former AAS users.

Anabolic Steroid Abuse and Sudden Death Risk

In a publication reviewing sudden cardiac deaths (SCDs) among AAS abusers, it was noted that there is an abnormal remodeling of the heart in this group of people and could result in an increased risk of life-threatening abnormal heart rhythms. This is different from the normal heart remodeling that occurs in athletes. The study also mentioned four possible ways that SCDs among AAS abusers can occur. First, it was mentioned the possible effect of severe plaque formation in the blood vessels that supply the heart causing a heart attack (atherogenic model). Secondly, it was stressed that the risk of sudden severe contractions of the blood vessels that supply the heart (vasospasm model) can predispose to SCD among AAS abusers. Thirdly, they stated that the formation of life-threatening clots within the blood vessels that supply the heart (thrombosis model) could also be responsible for SCD among AAS abusers, and finally, they noted that the SCDs in AAS abusers may result from direct toxicity to the heart’s muscle composition (Torrisi et al., 2020).

Clinical Approach to Treating Anabolic Steroid Toxicity on the Heart

Anabolic steroid-induced heart disease can vary from being asymptomatic to a severe heart failure state or causing sudden death. Clinical history-taking may uncover a history of substance abuse including AAS abuse. Physical examination may reveal evidence or signs of heart failure. Blood investigations including hormone panel studies, chest X-ray, blood gas studies, electrocardiogram, echocardiography, cardiac computed tomography, or magnetic resonance imaging studies may be needed to assess this group of patients. A multi-disciplinary care approach will be useful in the care of AAS abusers who develop notable heart complications from anabolic steroid abuse, and this could include the services of a cardiologist, endocrinologist, substance abuse unit, radiologist, specialist nurses, physiotherapist, occupational therapist, dietetics, and public health specialist. Stopping the use of the abused steroid(s) is the major step needed in a bid to achieve some recoverability of the heart’s impaired function. Seeking advice from a specialist in hormone disorders will be useful to manage steroid withdrawal effects in these patients. In addition, treating the ensuing heart failure is important using guideline-directed approach. In some cases, patients with life-threatening heart rhythm problems may need a pacemaker or implantable cardioverter defibrillator (devices for treating people with severe abnormal heart rhythms). In severe cases, devices that support the heart’s function may be used until a heart transplant is possible. It’s important to know that many heart transplant programs require patients to be completely drug-free to be considered for a transplant (Bui et al., 2019).

Proposed Public Health Intervention

Promoting awareness about the danger of AAS abuse cannot be over-emphasized. Recognition of the impact of this abuse problem by local, state, or federal stakeholders will go a long way toward putting in measures to curb the abuse problem. Educating people via the print and electronic media, in schools, on sportsgrounds, and in gyms will equally be useful. Enhancing the control of the flow of unauthorized steroids use within communities may need to be done.

Comments on References Cited

The publication by Melnik (2009) was a review article about AAS abuse problem in Germany. A more recent review article regarding this abuse problem could have been more useful. Different countries may have different experiences with AAS abuse problems. A future study detailing this multinational experience may reveal unique findings that could be adopted by countries more burdened with the problem of AAS abuse.

The publication by Gagnon et al. (2022) described the cardiovascular diseases that could complicate different abused substances. They noted that there could be a combined effect if these substances are used together. Studies detailing the speed of onset or severity of cardiovascular diseases when the different abused substances are used together could be done in the future to further assess.

The publication by Kanayama et al. (2018) was a review article summarizing other recent publications on the AAS abuse problem. More prospective and community-based interventional studies will be useful in relation to the topic under review.

The publication by Angelini et al. (2019) was a case report detailing an unreversed effect of AAS abuse on the heart in the affected patient with a form of heart failure. The case report is informative about the danger of chronic AAS exposure; however, more molecular and histologic studies of AAS-induced heart failure will need to be done. More systematic review studies about AAS-induced heart impairment will also be needed.

The publication by Gul and Shahid (2022) was a case report noting the reversal of heart failure features in a female who abused AAS for leisure purpose. In contrast to the above publication by Angelini et al., there was a reversal of heart failure features in the case reported by Gul and Shahid. More studies to determine the determinants of reversibility of heart failure features following AAS abuse will be needed. It could be preliminarily theorized that the impact of heavy exercise/gym sessions could worsen the impact of AAS abuse on the heart.

The publication by Singal et al. (2021) was also a case report, but it reviewed the impact of two forms of substance abuse: AAS abuse and mephentermine abuse. More systematic review articles on the combined effects of these abused substances with potential effects on the heart will need to be done.

The publication by Ha et al. (2018) was a case report explaining the lingering long-term effect of AAS abuse years after quitting its use. More tissue/radiologic studies to explain this lingering long-term effect will be needed. Where possible, larger prospective or cohort studies highlighting this effect will need to be done.

The publication by Vasilaki et al. (2016) revealing the outcome of a prospective animal model experiment in relation to AAS high dose use is noted. Ethical concerns may make such methodology unsuitable in human. However, a retrospective cohort study between those who abused AAS and those who did not may reveal notable findings.

The publication by Bulut et al. (2023) demonstrated the above point by reviewing the myocardial flow reserve in current and previous AAS users in relation to recreational athletes who did not abuse AAS in a community-based cross-sectional study.

The publication by Torrisi et al. (2020) was a literature review article that focused on the risk and possible causes of SCD among AAS abusers. Systematic review article publication on SCD among AAS abusers will be needed.

The publication by Bui et al. (2019) was both an opinion piece and having component systematic review in it. It gave insight to patients with abuse problems and their suitability for heart transplant. It noted that heart transplant programs would ideally want patients without substance abuse problems.

Conclusion

Primary prevention by promoting abstinence from AAS use is the best way to prevent the associated heart disease state that can accompany prolonged AAS misuse. More research to prevent unauthorized distribution of this abused substance in the community as well as research aimed at improving the impact on those with existing heart disease related to this condition should be encouraged. Public–private partnerships at curbing this abuse should be facilitated.