Researchers Reveal the Alarming Long-Term Risks of Steroid Use

[madman]

Strength/limitations (see following post)!

Researchers Reveal the Alarming Long-Term Risks of Steroid Use

Long-term study reveals alarming cardiovascular risks in steroid users, with some heart conditions up to nine times more likely.

www.emjreviews.com

A LONG-TERM study conducted in Denmark has revealed that male users of anabolic androgenic steroids (AAS) face significantly increased risks of cardiovascular disease compared to the general population.

Anabolic androgenic steroids, synthetic derivatives of testosterone used to enhance muscle mass and strength, have long been associated with health risks. While prohibited in competitive sports, their use remains widespread in recreational fitness settings. Previous research has linked AAS use to increased mortality rates, but the long-term cardiovascular effects have been underexplored. This study, published in Circulation, aimed to address this knowledge gap by examining the incidence of various cardiovascular diseases in AAS users over an extended period.

The researchers analysed data from 1,189 men sanctioned for AAS use in Danish fitness centres between 2006 and 2018, comparing them with 59,450 age-matched male controls from the general population. Over an average follow-up period of 11 years, AAS users demonstrated significantly higher incidences of several cardiovascular outcomes. The adjusted hazard ratios revealed stark differences: acute myocardial infarction (HR 3.00), percutaneous coronary intervention or coronary artery bypass graft (HR 2.95), venous thromboembolism (HR 2.42), arrhythmias (HR 2.26), heart failure (HR 3.63), and most notably, cardiomyopathy (HR 8.90). These results indicate that AAS users face risks of certain cardiovascular events that are two to nearly nine times higher than those of non-users.

These findings have significant implications for clinical practice and public health. Healthcare providers should be aware of the long-term cardiovascular risks associated with AAS use and incorporate this knowledge into patient assessments and counselling. The study underscores the need for targeted interventions and education programmes to discourage AAS use, particularly in recreational fitness settings. Future research should focus on understanding the mechanisms behind these increased risks and developing strategies to mitigate the long-term health consequences of AAS use. Additionally, long-term follow-up studies on former AAS users could provide valuable insights into the potential reversibility of these cardiovascular risks after cessation of use.

Katrina Thornber, EMJ

Reference

Windfeld-Mathiasen J et al. Cardiovascular disease in anabolic androgenic steroid users. Circulation. 2025;DOI:10.1161/CIRCULATIONAHA.124.071117.

https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.124.071117

 

[madman]

PODCAST (15:49-18:51)

Baseline age of these individuals 27 ± 7 years. So a relatively young population where we presume that cardiovascular diseases should be quite rare.

* we found quite alot of signals, associations and not only associations but quite strong associations

* the most striking finding was also a 9 fold incresed risk of cardiomyopathy

* mutiple severe cardiovascular diseases were actually significantly more common among users compared to controls






PODCAST (12:54-27:12)

https://www.ahajournals.org/do/10.1161/podcast.20250324.957173

This week please join author Josefine Windfeld-Mathiasen and Associate Editor Ntobeko Ntusi as they discuss the article "Cardiovascular Disease in Anabolic Androgenic Steroid Users."


Dr. Greg Hundley:

Welcome listeners. Now the transition from Peder and Shirin to our feature discussion today. And I'm with you, Dr. Greg Hundley, one of the associate editors, and I have with us today Dr. Josefine Windfeld-Mathiasen from the Department of Pharmacology in Copenhagen University, in Copenhagen, Denmark, and Dr. Ntobeko Ntusi from University of Cape Town in Cape Town, South Africa. Welcome to you both. And listeners, today we're going to hear from Josefine a fascinating study regarding anabolic androgenic steroids. So Josefine, starting into the question and answer part of this interview today, can you describe for us the background information that went into the preparation of your study, and what was the hypothesis that you wanted to address?




Dr. Josefine Windfeld-Mathiasen:

Well, thank you so much, Greg, for discussing this paper. Well, our theory behind the study was that anabolic steroids was associated with an increased of cardiovascular disease, including acute myocardial infarction, arrhythmias, cardiomyopathy, and heart failure. However, the evidence of this area is quite scarce, and this was also based on prior evidence linking anabolic steroids to precursors of cardiovascular disease, but also on findings from our own study actually on premature mortality, which we published last year in JAMA. So in this study, we observed that an increased mortality rate among anabolic steroid users. Within this group, cardiovascular disease was actually one of the most prevalent causes of a natural death. So this made us wonder.




Dr. Greg Hundley:

Very nice, and can you describe for us next your study design and your study population? Who did you include?

Dr. Josefine Windfeld-Mathiasen:

Yes. Yeah, for sure. Well, in Denmark we are very fortunate because we have exceptionally comprehensive population data and this allows us to follow up individuals across the entire country actually for many, many years. Additionally, we also have access to all hospital diagnosis nationwide. This provides us with a unique opportunity to track these disease progression among anabolic steroid users. And what we did here was we conducted a nationwide cohort study in Denmark using our national registries. And our study population consisted of male sanctioned for anabolic steroid use within an anti-doping program, that actually covered fitness centers in Denmark from 2006 and until 2018. Yeah, and these individuals were matched with controls from the general Danish population, based on age and sex. What we then did, we did some time-to-event analysis modeling to evaluate this incidence of cardiovascular events compared to controls, of course, adjusting for relevant confounding elements like age, diabetes, educational level, and occupational status.




Dr. Greg Hundley:

Super, and so, were the majority of these men? And then also, what was the range in age of those who were included in the study?

Dr. Josefine Windfeld-Mathiasen:

Well, they were men, beside 19 individuals, [inaudible 00:16:02] females. So primarily men, and we really hope that we can do a new study later on to include females of course, because this is very important to do on both sexes. So the baseline age of these individuals that we followed for 11 years of average were 27 years. So they were actually quite young, and of course they had an age band, I'll just find the exact confidence interval here for you. One second. So we have a confidence interval about seven years. So 27 plus-minus seven years. So a relatively young population where we presume that cardiovascular diseases should be quite rare.




Dr. Greg Hundley:

Super. Well, Josefine, and I know our listeners are just waiting to hear, what were your study results?

Dr. Josefine Windfeld-Mathiasen:

Yeah, well, we found quite a lot of signals, associations, and not only the associations but quite strong associations. So for this follow-up time of 11 years, we've observed significantly increased incident of cardiovascular disease compared to these control group. And specifically anabolic steroid users, they had actually a threefold increased risk of acute myocardial infarction. The most striking finding was also a ninefold increased risk of cardiomyopathy. And besides that, we also found an increased risk of undergoing coronary intervention. We found an increased risk of venous thromboembolism. We found an increased risk for arrhythmias and even heart failure. So multiple severe cardiovascular diseases were actually significantly more common among users compared to controls.




Dr. Greg Hundley:

Very nice, and Josefine, I know you mentioned myocardial infarction, were these all Type 1 myocardial infarction or Type 2? What was the breadth of that?

Dr. Josefine Windfeld-Mathiasen:

Oh, that's a good question. This where our limitations come into account because we needed to make sure that we address what we can actually see. So we have a overall estimate that is acute myocardial infarction, but we don't subclassify them into different types.




Dr. Greg Hundley:

And was that also the same for heart failure? Was it heart failure reduced or preserved ejection fraction, or was it just a definition, or an ICD-10 code, or what was used there to define the heart failure?

Dr. Josefine Windfeld-Mathiasen:

Exactly. So all these elements are defined by ICD-10 coding. So this makes some composite endpoints to make sure, because misclassification is just part of this, and to make sure that we have the strong signals, that's the most correct signals. We focused on the overall outcomes.




Dr. Greg Hundley:

Very nice. Well, that was just beautifully described Josefine, and thank you for just taking on this phenomenal project and then working with your national database to really answer this pivotal question. Well, listeners, next we're going to pivot to our own associate editor, Dr. Ntobeko Ntusi from Cape Town South Africa. And Ntobeko as an associate editor, I know you have many papers come across your desk, and so first, what attracted you to this particular paper? And then, second question, how do we put its results really in the context with other research ongoing regarding the use of anabolic steroids by younger men?




Dr. Ntobeko Ntusi:

Thank you, Greg. As an editor, I absolutely enjoyed editing this manuscript. For me, it had a number of strengths. The first was that it's the largest study of anabolic androgenic steroid use. As you've heard from Josephine, it confirms the harmful cardiovascular effects of these steroids.

The second area of strength was that it's a prospectively designed study with a relatively long duration of follow-up, a median of 11 years in the study period, which was conducted between 2006 and 2018.

Third, it exploits the strength of the Danish national health system as well as the availability of nationwide prospective health registries that allow us to be able to follow individuals within the Danish health system over time. Of course, as you've heard from Josephine, these really interesting observations about cardiovascular complications were made. For me, the most interesting and striking of these is the ninefold increase in the risk of development of cardiomyopathy and the nearly fourfold increase in the development of heart failure in young men on these anabolic steroids. Of course, it remains to be seen if these are sex specific or will be true in women too who also use anabolic steroids.

The results have to be interpreted with the limitations of this study, and for me there were two key limitations. The first was the inability of the investigational team to quantify either the duration or the dose of anabolic steroid use; of course, a limitation of using registry data.

The second is that many of these young men who take anabolic steroids may have been involved in other risk-taking behaviors. Despite the attempts at matching with healthy controls in the population, there's still fertile ground for residual confounding which may have influenced the results. Nonetheless, despite these limitations, I think these are really, really interesting observations, and I think when we look at this data in the context of what others have published in the field, for me there are four key clinical implications that are worth reflecting on.

The first implication is that this paper is the first to really highlight the need that those who have been detected, who have used anabolic androgenic steroids, need to be followed up for cardiovascular complications and that general practitioners, cardiologists and other healthcare workers need to be aware that these individuals they should have a higher index of suspicion for cardiovascular disease in them.

The second important implication for me is that amongst young athletes, especially young men, there is a clear need for public health education efforts to highlight the risk of harmful long-term cardiovascular consequences of steroid use. This is probably the most important message.

Then thirdly, and the most striking result for me as I've mentioned, related to the development of cardiomyopathy and heart failure, which in this paper were associated with severe reduction in left ventricular ejection fraction, striking diastolic dysfunction, but also myocyte hypertrophy as well as increased left ventricular mass. What this paper suggests is that the use of these androgenic anabolic steroids may actually have a direct toxic effect on the myocardium.

The fourth and last implication is that the question needs to be asked, what are the mechanisms through which steroids affect incident cardiovascular disease, and what are the mechanisms through which they result in a wide spectrum of cardiovascular complications? They affect multiple segments of the cardiovascular axis, as we can see from the results in this paper, suggesting that there may be a number of important mechanisms through which steroids effect their cardiovascular toxicity. So in closing, a really interesting manuscript, which I enjoyed handling as an editor and which I found particularly instructive as a scientist.




Dr. Greg Hundley:

Very nice, Ntobeko, and Josefine, he really tees you up for what do you see as the next study to be performed in this sphere of research?

Dr. Josefine Windfeld-Mathiasen:

Well, I could mention a long list to be honest, because I really find this need for more further research in this field. But given our findings, future research should focus on including female anabolic steroid users in our cohort, and this is a major priority in our research moving forward. Previously, the number of sanctioned women was too low to ensure anonymity, leading to their exclusion. However, as Anti-Doping Denmark, our collaborators in this cohort, sanction more women as we go on and we aim to investigate how these high doses of male sex hormones affect women's health as well, including of course their long-term cardiovascular risk.




Dr. Greg Hundley:

Very nice. And Ntobeko, your thoughts?

Dr. Ntobeko Ntusi:

So for me, Greg, I think there are three interesting future avenues for this work. First, there is a need to test whether the same observations hold in women. Second, we need to define the mechanisms of cardiovascular disease development from the use of these agents. Then third question relates to what is this study able to teach us about the use of steroids in general. As we already know, steroids, when taken, associated with increases in blood pressure, increased incident, chronic kidney disease, and increased risk of stroke, atherothrombosis and myocardial infarction. The mechanisms of cardiovascular complications from steroid use are poorly understood, and this paper gives us the opportunity to revisit some of these important questions.




Dr. Greg Hundley:

Very nice. And I think just to add to your comments, understanding those mechanisms could really lead us, and the social implications, to primary prevention, but another perhaps key area of investigation is secondary prevention. How do we reverse some of these effects? Well, listeners, we want to thank Dr. Josefine Windfeld-Mathiasen from the Department of Pharmacology in Copenhagen, Denmark, and also our own associate editor, Dr. Ntobeko Ntusi from University of Cape Town, in Cape Town, South Africa, for bringing us this really important study highlighting that anabolic androgenic steroids are associated with a substantial increase in the risk of cardiovascular disease, demonstrated in this relatively large cohort from Denmark and this brilliant long-term 11-year follow-up for individuals that averaged an age about 27 years. Well, on behalf of Peder, Shirin and myself, want to wish you a great week and we will catch you next week on the run.




Dr. Peder Myhre:

This program is copyright of the American Heart Association 2025. The opinions expressed by speakers in this podcast are their own and not necessary those of the editors or of the American Heart Association. For more, please visit ahajournals.org.

 

[madman]

https://jamanetwork.com/journals/jama/fullarticle/2816584#google_vignette

Mortality Among Users of Anabolic Steroids
Josefine Windfeld-Mathiasen, MD1; Ida M. Heerfordt, MD, PhD1; Kim Peder Dalhoff, MD, DMSc1; et al

 

[madman]

Summary Points

• Testosterone, the main endogenous active androgen, is used to treat many clinical conditions

• Testosterone and other androgens are also used by athletes, non athlete weightlifters or bodybuilders to enhance muscle development, strength, and performance and endurance

• Testosterone at supraphysiological levels increases cardiovascular disease risk, causes myocardial infarction, stroke, high blood pressure, blood clots, and heart failure

• Testosterone affects the cardiovascular system by changing lipid profile, insulin sensitivity, hemostatic mechanisms, sympathetic nervous system, and renin angiotensin-aldosterone system

• Testosterone activates proinflammatory and redox processes, decreases nitric oxide bioavailability, and stimulates vasoconstrictor signaling pathways

• Testosterone affects the vasculature by interfering with all mechanisms that control vascular function

• In the endothelium, testosterone modulates NO, COX-derived metabolites and EDHF release and signaling

• In VSMCs, testosterone modulates ROS generation, expression, and activity of receptors and ion channels

Thread 'High Testosterone Levels: Impact on the Heart'

Mar 9, 2024

Abstract

Testosterone, the main endogenous active androgen, is used to treat many clinical conditions, such as hypogonadism, infertility, erectile dysfunction, osteoporosis, anemia, and in transgender therapy (female-to-male transsexuals). Androgens are also used by athletes to enhance performance and endurance, and by non athlete weightlifters or bodybuilders to enhance muscle development and strength. Accordingly, testosterone and other anabolic-androgenic steroids are the main class of appearance and performance enhancing drugs (APEDs), i.e., substances used to improve...

• madman
• testosterone/aas; cvd; ar; endothelial; no
• Replies: 4
• Forum: Testosterone and Men's Health Articles

• 

 

[Guided_by_Voices]

I click all the links I saw here and didn't see any actual underlying data on the AAS use and other related markers. For example it would have been nice to know things like how much of the issue was due to uncontrolled blood pressure, what was the comparison of dose/duration to event type and likelihood, were some compounds worse than others, etc. The problem with these studies is that they seem to be done by people who assume AAS have no benefit, so they don't look for data that would show how to achieve benefits while minimizing harm.

 

[madman]

I click all the links I saw here and didn't see any actual underlying data on the AAS use and other related markers. For example it would have been nice to know things like how much of the issue was due to uncontrolled blood pressure, what was the comparison of dose/duration to event type and likelihood, were some compounds worse than others, etc. The problem with these studies is that they seem to be done by people who assume AAS have no benefit, so they don't look for data that would show how to achieve benefits while minimizing harm.

You might want to look into who some of those authors of the paper are before you go on flapping your gums!

Even when harm reduction strategies are implemented it is not a given that there is no negative effects on the cardiovascular system long-term.

No free lunch here.

Abusing T/AAS may have a direct toxic effect on the cardiac muscle.




10.1161/podcast.20250324.957173

* The results have to be interpreted with the limitations of this study, and for me there were two key limitations. The first was the inability of the investigational team to quantify either the duration or the dose of anabolic steroid use; of course, a limitation of using registry data.

* The second is that many of these young men who take anabolic steroids may have been involved in other risk-taking behaviors. Despite the attempts at matching with healthy controls in the population, there's still fertile ground for residual confounding which may have influenced the results.

* Nonetheless, despite these limitations, I think these are really, really interesting observations, and I think when we look at this data in the context of what others have published in the field, for me there are four key clinical implications that are worth reflecting on.








You need to look over the strengths and limitations of the study!

https://www.ahajournals.org/doi/abs/10.1161/CIRCULATIONAHA.124.071117

Anabolic Steroid Use Linked to Higher Risk for Heart Attack

A study of Danish men reveals that the use of anabolic androgenic steroids is associated with a substantial increase in the risk for multiple cardiovascular diseases.

www.medscape.com