Anabolic-androgenic steroids: worse for the heart than we knew?

The use of anabolic-androgenic steroids (AAS) among athletes is not new, nor is concern about their potential cardiac effects, but it has been difficult to definitively document deleterious cardiovascular effects from these drugs. There are case reports of unexpected myocardial infarctions1 and even sudden cardiac death2 in AAS users, but such reports are relatively rare given the reported widespread use of AAS. Moreover, their effects on cardiovascular risk factors are confusing. Oral synthetic steroids, such as stanozolol, reduce high-density lipoprotein and increase low-density lipoprotein cholesterol more than parenterally administered testosterone at similar androgenic doses,3 suggesting that oral AAS are more atherogenic, but both stanozolol4 and testosterone5 decrease lipoprotein (a), an important atherosclerotic risk factor. There is also concern that AAS increase blood pressure, but even the literature on this topic is equivocal,6 and some of the purported increase in blood pressure with AAS may be due to the use of undersized sphygmomanometer cuffs in subjects with increased arm circumference.7 Consequently, the overall clinical effect of AAS use on atherosclerotic risk and events is not clear.