Sudden Cardiac Death in Anabolic-Androgenic Steroid Users: A Literature Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Database Search Terms and Timeline
2.2. Inclusion and Exclusion Criteria
2.3. Study Selection
3. Results
4. Discussion
5. Conclusions
Author Contributions
Funding
Acknowledgments
Conflicts of Interest
Appendix A
Author (Year) | Age (Years); Sex; Height; Weight | BMI | Personal and Family Medical History | Kind of Sport Activity | ASS Reported Use—Time of Assumption | Use of Other Drugs | Circumstance of Death | Macroscopic Heart Findings | Histological Heart Findings | Toxicological Analysis | Cause of Death |
Campbell, S. E. et al. (1993) | 21; M | NR | Absence of significant diseases | Bodybuilder | Testosterone; nandrolone—several months | NR | Collapse during a weight-lifting workout at the gym | 530 g—Marked left and right ventricular hypertrophy | Extensive perivascular fibrosis of intramural coronary arteries—interstitial fibrosis | NR | Unspecified SCD |
Dickerman, R. D. et al. (1995) | 20; M; 180 cm; 100.7 kg | 31.08 | No past or family history of cardiac disease | Bodybuilder | Methenolone depot; veterinarian testosterone enanthate—just complete a 3-month cycle | NR | Sudden witnessed death | 515 g (0.51% of body weight)—Signs of concentric left ventricular hypertrophy | Mild atherosclerosis | NR | Unspecified SCD |
Hausmann, R. et al. (1998) | 23; M; 192 cm; 94 kg | 25.50 | NR | Bodybuilder | Testosterone cyclopentilpropionate; methenolone enanthate; mesterolone—9 months | Other performance-enhancing drugs (liothyronine hydrochloride, clenbuterol hydrochloride) | Found unconscious at home in his bed | 500 g (0.53% of body weight)—Cardiac hypertrophy, right ventricle dilatation, focal induration of endocardium | Enlargement and nuclear polymorphism of the left ventricular muscle fibers. Disseminated focal necrosis and interstitial fibrosis | Urine: Mesterolone, methandienone, testosterone, nandrolone, clenbuterol | Unspecified SCD |
Fineschi, V. et al. (2001) | 32; M; 189 cm; 90 kg | 25.20 | No history of disease | Bodybuilder | Testosterone propionate; nandrolone—several months | NR | Sudden loss of consciousness during a weight lifting workout | 450 g (0.50% of body weight)—Normal heart measures (14 × 14 × 4 cm)—Normal valves, endocardium, and coronary arteries—one grayish zone in the left ventricle myocardium | Infarct necrosis corresponding to the grayish zone—some foci of contraction band necrosis and fibrosis | Urine: Metabolites of nandrolone, metabolites of stanozolol | SCD most likely related to adrenergic stress |
29; M; 166 cm; 72 kg | 26.13 | His medical history was unremarkable | Bodybuilder | Nandrolone; stanozolol—several months | NR | Found unconscious at home in his bed | 390 g (0.54% of body weight)—Normal heart measures (11 × 10 × 5 cm)—Normal valves, endocardium, and coronary arteries | Occasional isolated myocardial cells with contraction band and segmentation | Urine: Metabolites of nandrolone, metabolites of stanozolol | Unspecified SCD | |
Fineschi, V. et al. (2005) | 30; M; 178 cm; 90 kg | 28.41 | NR | Bodybuilder | Nandrolone decanoate—6 months | Unspecified other drugs | Sudden collapse at home | 400g (0.44% of body weight) —Scattered fatty streaks in coronary arteries | Focal myocardial fibrosis | Urine: Norandrosterone. Blood: nandrolone | Unspecified SCD |
Di Paolo, M. et al. (2007) | 29; M; 190 cm; 127 kg | 35.2 | No prior history of disease. No family history of cardiac disease under the age of 50 | Bodybuilder | History of use of unspecified AAS—unspecified | NR | Sudden loss of consciousness during the first minutes of a spin bike lesson | 490 g (0.39% of body weight)—Normal hearth wall thickness, normal valve, normal coronary arteries | Severe epicardial interstitial fibrosis, small vessel disease | Negative | Unspecified SCD |
27; M; 190 cm; 100 kg | 25.8 | No prior history of disease. No family history of cardiac disease under the age of 50 | Bodybuilder | History of use of unspecified AAS—unspecified | NR | Sudden illness while he was at a night club | 360 g (0.36% of body weight)—Normal hearth wall thickness, normal valve, normal coronary arteries | Mild focal epicardial interstitial fibrosis, small vessel disease | Urine: Stanozolol, testosterone | Unspecified SCD | |
37; F; 161 cm; 71 kg | 27.4 | No prior history of disease. No family history of cardiac disease under the age of 50 | Bodybuilder and weight lifter | History of use of unspecified AAS—unspecified | NR | Found dead in her car | 310 g (0.44% of body weight) —Normal hearth wall thickness, normal valve, normal coronary arteries | Moderate focal epicardial interstitial fibrosis, small vessel disease | Negative | Unspecified SCD | |
31; M; 175 cm; 79 kg | 25.8 | No prior history of disease. No family history of cardiac disease under the age of 50 | Bodybuilder | History of use of unspecified AAS—unspecified | NR | Found dead in his bedroom: alive 7 h before | 400 g (0.51% of body weight)—Normal hearth wall thickness, normal valve, normal coronary arteries | Moderate epicardial interstitial fibrosis, small vessel disease | Urine: Stanozolol | Unspecified SCD | |
Fanton, L. et al. (2009) | 19; M | NR | No history of cardiac disease | Weight lifter | History of use of unspecified AAS—unspecified | NR | SD during training | 360 g—Left ventricle apoplexy | Multiple focal areas of necrosis, myolysis, scarring fibrosis | NR | Unspecified SCD |
22; M | NR | No history of cardiac disease | PE teacher | History of use of unspecified AAS—unspecified | NR | SD during training | 520 g—Left ventricle apoplexy | Multiple focal areas of necrosis, myolysis, scarring fibrosis | NR | Unspecified SCD | |
25; M | NR | No history of cardiac disease | Bodybuilder | History of use of unspecified AAS—unspecified | NR | SD during training | 460 g—Disseminated myocarditis | Multiple focal areas of necrosis, myolysis, scarring fibrosis | NR | Unspecified SCD | |
28; M | NR | No history of cardiac disease | Soccer player | History of use of unspecified AAS—unspecified | NR | SD during training | 380 g—Disseminated myocarditis | Multiple focal areas of necrosis, myolysis, scarring fibrosis | NR | Unspecified SCD | |
54; M | NR | No history of cardiac disease | Marathon runner | History of use of unspecified AAS—unspecified | NR | SD during training | 410 g—Coronary thrombosis and dilated cardiomyopathy | multiple focal areas of necrosis, myolysis, scarring fibrosis | NR | Unspecified SCD | |
48; M | NR | No history of cardiac disease | Marathon runner | History of use of unspecified AAS—unspecified | NR | SD during training | 430 g—Left ventricle hypertrophy | Multiple focal areas of necrosis, myolysis, scarring fibrosis | NR | Unspecified SCD | |
Thiblin, I. et al. (2009) | 29; F; 172 cm; 76 kg | 25.7 | No history of disease | Fitness athlete | History of use of unspecified AAS—unspecified | Unspecified other drugs | Found naked in a prone position on the floor beside her bed, with a pillow partly under her body | 331 g (0.44% of body weight)—Normal heart measures—Normal coronary arteries, with an isolated flat area of fatty thickening in the proximal part of the left anterior descending (LAD) coronary artery. | Lymphocytic infiltration around several middle-sized and small intramural vessels—minimal myocardial necrosis | Blood: ephedrine, norephedrine. Urine: testosterone, metabolites of stanozolol, boldenone | Sudden cardiac arrhythmia, possibly related to the combination of an otherwise unspecified inflammatory process in the heart and the acute influence of ASS and ephedrine |
Montisci, M. et al. (2012) | 32; M; 180 cm; 110 kg | 33.95 | NR | Bodybuilder | History of use of unspecified AAS—7 years (recently withdraw) | NR | Found dead at home in his bed | 450 g (0.41% of body weight)—11 × 9.5 cm—cardiomegaly, concentric left ventricular hypertrophy, normal valve, normal coronary arteries | Hypertrophic myocytes, focal disarray, interstitial and replacement fibrosis, foci of lymphoplasma cellular infiltrates (CD3+), with edema and patchy necrosis | Negative | Concentric left ventricular hypertrophy, focal acute myocarditis. |
32; M; 178 cm; 94 kg | 29.67 | At last screening, nonspecific repolarization changes were found at ECG | Cycler | History of use of unspecified AAS—several years | NR | SD after a dentistry visit | 580 g (0.62% of body weight)—12.5 × 11 cm—Cardiomegaly, hypertrophy, biventricular dilatation, normal valve, non-obstructive LAD stenosis | Hypertrophic myocytes, foci of necrosis, replacement fibrosis, LAD 50% stenosis, fibrofatty replacement | Negative | Inflammatory dilated cardiomyopathy with subacute-chronic stages, hemorrhagic pulmonary infarction | |
25; M, 185 cm; 125 kg | 36.52 | An ECG performed 5y before death was normal | Bodybuilder | Circumstantial finding of unspecified use of AAS—unspecified | Unspecified other performance-enhancing drugs | SD while sleeping | 390 g (0.31% of body weight)—10.5 × 9.5 cm—normal hearth wall thickness, normal valve, normal coronary arteries | Inflammatory infiltrate, myocyte necrosis | Urine: Testosterone, epitestosterone, nortestosterone | Eosinophilic myocarditis | |
Lusetti, M. et al. (2015) | 39 (mean age); M (All 6 cases) | NR | NR | NR | History of use of unspecified AAS—unspecified | NR | Sudden unwitnessed death | Normal hearth wall thickness, normal valve, normal coronary arteries. In one case: 490 g (0.54% of body weight) | Interstitial fibrosis (6 cases); perivascular fibrosis (4 cases); perineural fibrosis within the left ventricle (2 cases); fibroadipous metaplasia (2 cases); contraction band necrosis (2 cases); Myocyte segmentation (2 cases); Intercalated disc widening (2 cases); myocyte hypertrophy (3 cases); coronary intimal and media thickening (4 cases) | Blood: Ethanol (1 case). Urine and hair: nandrolone (3 cases), Testosterone (3 cases) | Sudden cardiac arrhythmia |
Lichtenfeld, J. et al. (2016) | 13; M | NR | No prior history of disease. An episode of syncope with exertion 1 week before cardiac arrest. No family history of sudden death, hypertrophic cardiomyopathy, or heart rhythm abnormalities | Sprinter | Physical Phenotype suggesting AAS use | NR | Sudden cardiac arrest while performing timed wind sprints at a competitive sports camp | 465 g—Cardiomegaly, marked LV Hypertrophy | Foci of myofibrillar disarray, the proliferation of fibroblasts consistent with early fibrosis, and enlarged myofibers with the heterogeneity of nuclear size including “box-car” nuclei | NR | Sudden cardiac arrest followed by brain death |
Lusetti, M. et al. (2018) | 32; M | NR | No “officially” medically prescribed drug treatment at the time of death. | NR | History of use of unspecified AAS—unspecified | NR | unspecified SD | 390 g—Left ventricular hypertrophy | Myocardial fibrosis | Urine: Nandrolone, Testosterone. Blood: Methadone, Citalopram, Clozapine, Venlafaxine, Lorazepam, Phenobarbital, THC | Unspecified SCD |
32; M | NR | No “officially” medically prescribed drug treatment at the time of death. | NR | History of use of unspecified AAS—unspecified | NR | unspecified SD | 360 g | Fatty streaks, intima, and media thickening within the coronary arteries | Urine: Boldenone, Clomiphene, Methenolone, Oxandrolone, Stanozolol. Blood: Lorazepam, THC | Unspecified SCD | |
33; M | NR | No “officially” medically prescribed drug treatment at the time of death. | NR | History of use of unspecified AAS—unspecified | NR | unspecified SD | 425 g—Left ventricular hypertrophy | Myocyte necrosis | Urine: Testosterone. Blood: Methadone, Cocaine | Unspecified SCD | |
39; M | NR | No “officially” medically prescribed drug treatment at the time of death. | NR | History of use of unspecified AAS—unspecified | NR | unspecified SD | 480 g—Left and right ventricular hypertrophy | Myocyte necrosis, Myocardial fibrosis | Urine: Nandrolone. Blood: Morphine, THC | Unspecified SCD | |
29; M | NR | No “officially” medically prescribed drug treatment at the time of death. | NR | History of use of unspecified AAS—unspecified | NR | unspecified SD | 340 g | NR | Urine: Nandrolone, Testosterone. Blood: morphine, THC, Ethanol | Unspecified SCD | |
Hernandez-Guerra, A. I. et al. (2019) | 24; M; 178 cm; 85 Kg | 26.8 | No past or family history of cardiac disease. One episode of precordial pain some months before. | NR | stanozolol, testosterone, mesterolone, nandrolone—6 months | tamoxifen | Sudden death at home | 420 g (0.49% of body weight)—Cardiomegaly, Normal ventricular thickness, >75% Stenosis of the left main trunk and the LAD, areas of scarring located at the intersection between the posterior wall and the posterior third of the septum | Acute myocardial infarction, myocytes hypertrophy, small intramyocardial vessel disease | Blood: Ethanol, Stanozolol, Nandrolone | Acute myocardial infarction |
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Author | Year | Number of Cases | Study Type |
---|---|---|---|
Campbell, S.E. et al. [37] | 1993 | 1 | Case report |
Dickerman, R.D. et al. [38] | 1995 | 1 | Case report |
Hausmann, R. et al. [39] | 1998 | 1 | Case report |
Fineschi, V. et al. [40] | 2001 | 2 | Case series |
Fineschi, V. et al. [41] | 2007 | 1 1 | Case series |
Di Paolo, M. et al. [42] | 2007 | 4 | Letter to the editor |
Fanton, L. et al. [43] | 2009 | 6 2 | Retrospective study |
Thiblin, I. et al. [44] | 2009 | 1 | Case report |
Montisci, M. et al. [45] | 2012 | 3 3 | Case series |
Lusetti, M. et al. [46] | 2015 | 6 | Retrospective study |
Lichtenfeld, J. et al. [47] | 2016 | 1 | Case report |
Lusetti, M. et al. [48] | 2018 | 5 | Retrospective study |
Hernandez-Guerra, A.I. et al. [1] | 2019 | 1 | Case report |
Toxicological Findings | Number of Cases | % of Total Cases |
---|---|---|
Nandrolone | 10 | 30% |
Testosterone | 9 | 27% |
Stanozolol | 7 | 21% |
Boldenon | 2 | 6% |
Norandrosterone | 1 | 3% |
Mesterolone | 1 | 3% |
Methandienone | 1 | 3% |
Epitestosterone | 1 | 3% |
Nortestosterone | 1 | 3% |
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Torrisi, M.; Pennisi, G.; Russo, I.; Amico, F.; Esposito, M.; Liberto, A.; Cocimano, G.; Salerno, M.; Li Rosi, G.; Di Nunno, N.; et al. Sudden Cardiac Death in Anabolic-Androgenic Steroid Users: A Literature Review. Medicina 2020, 56, 587. https://doi.org/10.3390/medicina56110587
Torrisi M, Pennisi G, Russo I, Amico F, Esposito M, Liberto A, Cocimano G, Salerno M, Li Rosi G, Di Nunno N, et al. Sudden Cardiac Death in Anabolic-Androgenic Steroid Users: A Literature Review. Medicina. 2020; 56(11):587. https://doi.org/10.3390/medicina56110587
Chicago/Turabian StyleTorrisi, Marco, Giuliana Pennisi, Ilenia Russo, Francesco Amico, Massimiliano Esposito, Aldo Liberto, Giuseppe Cocimano, Monica Salerno, Giuseppe Li Rosi, Nunzio Di Nunno, and et al. 2020. "Sudden Cardiac Death in Anabolic-Androgenic Steroid Users: A Literature Review" Medicina 56, no. 11: 587. https://doi.org/10.3390/medicina56110587