Impact of Androgenic Anabolic Steroids on Cardiovascular Health in Men and Women - PART OF THE FITNESS DOPING IN DENMARK (FIDO-DK) STUDY
Authors: Buhl Laust Frisenberg , Christensen Louise Lehmann , Hjortebjerg Rikke , Hasific Selma , Hjerrild Clara , Harders Stefan , Lillevang-Johansen Mads , Glintborg Dorte , Andersen Marianne S. , Thevis Mario , Kistorp Caroline , Rasmussen Jon Jarløv , Lindholt Jes S. , Diederichsen Axel , Frystyk Jan 
Published: November 2024

Background

Illicit use of anabolic androgenic steroids (AAS) is common among recreational athletes, yet comprehensive studies on adverse cardiovascular outcomes, especially in female AAS users, are lacking.

Methods

A cross-sectional study of recreational athletes of women and men was conducted, involving active and previous AAS users and non-users aged ≥18 years. Previous use was defined as discontinuation of AAS at least three months prior to study. Primary outcomes included atherosclerosis (carotid, femoral, and coronary artery plaques) and cardiac function, assessed using vascular ultrasound, coronary computed tomography angiography and echocardiography.

Results

Median age was 36 years for active users (n=80, 19 women), 35 years for previous users (n=26, 8 women), and 40 years for non-users (n=58, 16 women) (p=NS). Median AAS usage period was 2.2 years for both active and previous users; the latter group had discontinued intake 2.5 years before study (range: 3 months to 29 years).

There was no group differences when comparing the number of femoral/carotid artery plaques, the coronary artery calcium (CAC) score or the number of non-calcified plaques. However, confounder-adjusted logistic regression showed associations between cumulative AAS use and a positive CAC score (OR: 1.23, 95% CI: 1.09–1.39, p=0.001) and the presence of non-calcified plaque (OR: 1.17, 95% CI: 1.05–1.30, p=0.004), respectively, when comparing previous and ongoing users vs. non-users. These associations were also present in men, but not women. Moreover, >5 years of AAS use increased the fraction of athletes with increased severity of calcifications (p=0.043). Echocardiography showed that active AAS using males and females had impaired left ventricular global longitudinal strain (LVGLS) and right ventricular global longitudinal strain (RVGLS) compared to sex-matched non-users (p<0.001). Multivariable analysis showed that cumulative AAS use correlated with worsening of LVGLS (p=0.002) and RVGLS (p=0.001). Finally, after 5 years of cumulative AAS use, nearly all athletes had ventricular mass above and left ventricular ejection fraction below the median of normal range.

Conclusion

In men, the cumulative lifetime AAS exposure was an independent predictor of coronary atherosclerosis. However, both male and female AAS users share risks of myocardial dysfunction, underscoring significant cardiovascular risks across genders.

CLINICAL PERSPECTIVE

Key observations from the study:

In recreational athletes, the accumulated lifetime AAS exposure associates with a higher prevalence of non-calcified plaques and coronary artery calcification in male recreational athletes.

Our study suggests that more than 5 years of AAS use constitutes a threshold beyond which the development of coronary calcifications significantly increases compared to non-users.

In addition to compromised left ventricular systolic and diastolic function, AAS users exhibited significantly reduced right ventricular function, indicating a biventricular cardiac impact of AAS.

Male and female AAS users showed similar patterns of cardiac deterioration.

These findings highlight the significant cardiovascular risks associated with AAS use in both male and female recreational athletes, underscoring the importance of targeted research, educational programs, information campaigns, and intervention strategies for this population, regardless of gender.