Juniper Publishers- Open Access Journal of Case Studies
Heart Failure Due to Anabolic-Androgenic Steroids Abuse: A Case Report
Authored by Badr Eslam R
Abstract
Anabolic-androgenic steroids (AAS, prominent examples include Nandrolone, Clenbuterol and Stanozolol) act as valuable treatment options for people presenting with hypogonadism and stimulate erythropoiesis in bone marrow failures [1]. However, a growing number of people misuse AAS in order to obtain a muscular body shape and enhance their physical performance. The use of anabolic steroids has increased rapidly in the last few years, not only being used by bodybuilders, but also casual fitness enthusiasts [2].
We report the case of a 25-year-old man, who suffered from heart failure as a result of massive use of anabolic steroids over only three months. Initially blood samples and echocardiography parameters were collected. A biopsy was taken by which myocarditis could be excluded. Heart failure was assessed using cardiac MRI. Medical treatment with Valsartan/Sacubitril was implemented and regular check-ups were performed. After four months ejection fraction returned to normal levels.
To conclude, physicians and athletes should be aware of the possible serious acute and long-term side effects of AAS consumption. Moreover Valsartan/Sacubitril seems to be effective in treating heart failure due to AAS abuse. However, further clinical trials are required to verify these effects.
Keywords:Heart failure; AAS; Sacubitril/Valsartan
Abbreviations: AAS: Anabolic-Androgenic Steroids; ALAT (GPT): Alanine Aminotransferase (Glutamate-Pyruvate Transaminase); ASAT (GOT): Aspartate Amino Transferase (Glutamic Oxaloacetic Transaminase); Gamma-GT: Gamma-Glutamyl Transferase; bpm: Beats per Minute; NT-proBNP: N-Terminal pro B-type Natriuretic Peptide; LVEF: left Ventricular Ejection Fraction; HF: Heart Failure; CPET: Cardiopulmonary Exercise Testing
Introduction and Background
Anabolic-androgenic steroids (AAS) not only have a therapeutic use, but are also used by athletes to improve their physical performance [1]. The last few years the abuse of AAS has increased, as they are used by high-level sportsmen and also casual fitness enthusiasts [2]. The substances used include the male hormone testosterone and its synthetic derivates. The illicitly use of AAS often results in blood concentrations more than 100 times the physiological blood levels. In supraphysiological dosages AAS cause numerous side effects that involve most organ systems. However, the most severe side effects pertain to the cardiovascular system and may cause hypertension, sudden cardiac death, intracoronary thrombi, atrial and ventricular arrhythmias and cardiomyopathy [3].
Case Presentation
This is a case report of a 25-year-old man who presented with progressive dyspnea and orthopnea as well as tachycardia (heart rate: 180bpm). The patient had a history of anabolic steroid abuse over the past 3 months with testosterone.
Initial work up
Laboratory assessment showed an elevated NT-proBNP level (1030pg/mL) as well as elevated liver enzymes (ALAT (GPT): 112U/L; ASAT (GOT): 35U/L; Gamma-GT: 79U/L). Echocardiography showed severe left ventricular dilatation, highly impaired left ventricular systolic function as well as a slow flow of the left ventricle without thrombus. The patient underwent coronary angiography to exclude stenosis of the coronary arteries. At the same time a biopsy of the left ventricle was taken, which excluded myocarditis. His clinical condition deteriorated rapidly requiring intubation within hours after first presentation, two days after initial onset of symptoms. Cardiac magnetic resonance imaging revealed a left ventricular ejection fraction (LVEF) of 28% (Table 1).
Diagnosis and management
The patient was admitted to the ICU with cardiogenic shock. A diagnosis of dilated cardiomyopathy resulting in cardiorespiratory insufficiency associated with anabolic steroids was made after ruling out other causes of non-ischemic dilated cardiomyopathy. Sacubitril/ Valsartan was given in an initial dose of 24mg/26mg and titrated up to a maximum dose of 97mg/103mg. At the time of discharge the patient was provided with a LifeVest (ZOLL, Cologne, Germany).
Follow-up
The follow up visit one month after initial presentation showed an increase of LVEF from initially 28% to 32.7%. The left ventricle was still significantly enlarged. Due to close follow up and constant therapy optimization a LVEF of 62% (reference range: 55-70%) could be achieved 4 months later, obviating the need for carrying a LifeVest. The patient resumed his training 3 times per week. Cardiopulmonary exercise testing (CPET) was performed 9 months after establishing the diagnosis to exclude cardiac limitation at exertion. The test showed a VO2 max of 3147ml/min (96% of predicted peak oxygen uptake value) and a VE/VCO2 (ventilatory equivalent of carbon dioxide) slope of 21.38, which was within the normal range. The patient could now resume with his normal training routine.
Discussion and Conclusion
Sacubitril/ Valsartan seem to be an effective and good therapy for heart failure due to anabolic-androgenic steroid abuse and contribute to the improvement of the left ventricular ejection fraction rapidly.
Cardiopulmonary exercise testing (CPET) presents a complete assessment of exercise concerning the pulmonary, cardiovascular, muscular and cellular oxidative systems [4]. The application of CPET in the management of patients with heart failure (HF) is valuable to make activity recommendations, quantify the response to therapy and exclude cardiac limitation at exertion. Especially powerful in evaluating risk in HF are indices of ventilatory inefficiency, such as peak VO2 and VE/VCO2 slope [5]. The spread of anabolic androgenic steroids abuse among athlete’s worldwide calls for Physicians to caution users about the serious risk of possible long-term cardiac complications linked with AAS (Figure 1 & 2).
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