Introduction
The non-medical use of anabolic androgenic steroids (AAS) remains prevalent among recreational athletes, driven by desires for enhanced physical performance and aesthetics. Despite their popularity, evidence regarding the long-term cardiovascular consequences, especially among women, remains limited. The recent Danish cross-sectional study by Buhl et al. provides critical insights into the structural and functional cardiac changes associated with illicit AAS use in both men and women.
Study Background and Clinical Context
Anabolic steroids are synthetic derivatives of testosterone, widely misused outside clinical settings for muscle mass augmentation. Previous studies have linked AAS to hypertensive states, dyslipidemia, and structural cardiac changes. However, data focusing on women, who are often underrepresented, and comprehensive assessments combining imaging and plaque detection were scarce. This gap signifies a substantial unmet medical need to understand sex-specific risks and develop targeted prevention strategies.
Study Design and Methods
This Danish single-center, cross-sectional study recruited 164 recreational athletes aged 18 years and older from fitness centers between March and December 2022. Participants were categorized into three groups based on AAS use history: active users, previous users (discontinued at least three months prior), and nonusers. Data collection included detailed interviews on lifetime AAS exposure, clinical assessments, blood tests, echocardiography for ventricular function, and imaging (carotid, femoral, and coronary arteries) for plaque detection. Primary endpoints encompassed the presence of atherosclerosis, calcification, coronary noncalcified plaques, and ventricular function parameters.
Key Findings and Results
The study provided several noteworthy results:
— Among 164 participants, 80 (48.8%) were current AAS users, predominantly men. Previous users and nonusers constituted the rest.
— Median cumulative lifetime AAS use was approximately 2.2 years across active and previous users.
— The prevalence of femoral, carotid, and coronary artery plaques did not significantly differ among groups, and median coronary artery calcium (CAC) scores were zero across all groups, indicating no widespread calcification.
— However, a notable exception was the higher prevalence of coronary noncalcified plaques (NCPs) in active AAS users (23.8%) compared to nonusers (10.3%), with statistical significance (P=0.03).
— Importantly, longer AAS exposure correlated with increased odds of positive CAC scores (OR, 1.23) and presence of NCPs (OR, 1.17), after adjusting for confounders.
— AAS use exceeding five years was associated with increased severity of calcification (p=0.04).
— Echocardiography revealed that cumulative AAS use adversely affected ventricular function, with worse global longitudinal strain for both left and right ventricles. Participants with >5 years of use showed marked ventricular hypertrophy and reduced ejection fractions.
Expert Commentary
This study robustly links prolonged AAS exposure with structural and functional cardiovascular alterations. The findings underscore that even in the absence of overt plaques or calcifications, subclinical myocardial dysfunction occurs, greatly raising concern for future heart failure or ischemic events. The observed sex-neutral adverse effects highlight that women engaging in illicit AAS use are equally at risk, often overlooked in research. Limitations include the cross-sectional design, which precludes causal inferences, and the relatively young cohort, which may underestimate long-term risks.
The biological plausibility lies in AAS-induced hypertrophy, increased myocardial workload, and accelerated atherogenesis due to dyslipidemia and hypertension. These findings advocate for stricter enforcement of anti-doping measures and enhanced educational initiatives targeting recreational athletes, emphasizing cardiovascular risks.
Conclusion and Future Directions
In conclusion, illicit AAS use is associated with significant adverse cardiovascular changes in both men and women, particularly with longer exposure durations. The evidence supports urgent public health interventions to prevent AAS use and underscores the necessity for longitudinal studies to elucidate the progression and reversibility of these findings. Healthcare providers should incorporate cardiovascular screening and counseling in at-risk populations engaging in anabolic steroid misuse.
References
– Buhl LF, Christensen LL, Hjortebjerg R, et al. Illicit Anabolic Steroid Use and Cardiovascular Status in Men and Women. JAMA Netw Open. 2025;8(8):e2526636. doi:10.1001/jamanetworkopen.2025.26636
– Hartgens F, Kuipers H. Effects of androgenic-anabolic steroids in athletes. Sports Med. 2004;34(8):513-554.
– Baggish AL, Weiner DA, Wang F, et al. Longitudinal changes in left ventricular structure and function in response to anabolic-androgenic steroids. J Am Coll Cardiol. 2010;55(20):2112-2120.
Overall, this study sheds light on the silent, yet profound, cardiovascular effects of AAS abuse, demanding heightened awareness and preventive action in healthcare and sports communities.
