ANABOLIC STEROID ABUSE AND CARDIOVASCULAR TOXICITY: CASE REPORT

Despite the development of tests for the detection of doping, Anabolic steroids, are still used to increase sports performance. Unfortunately, studies have clearly shown that overdose of anabolic steroids can induce serious cardiovascular complications that can be life-threatening. This implies the determining role of health professionals in informing the general population and athletes in particular about the lethal effect of these substances. We report the case of a young high-level athlete who consults for palpitations and in whom cardiac imaging reveals abnormalities related to chronic consumption of anabolic steroids.

Despite the development of tests for the detection of doping, Anabolic steroids, are still used to increase sports performance. Unfortunately, studies have clearly shown that overdose of anabolic steroids can induce serious cardiovascular complications that can be lifethreatening. This implies the determining role of health professionals in informing the general population and athletes in particular about the lethal effect of these substances. We report the case of a young highlevel athlete who consults for palpitations and in whom cardiac imaging reveals abnormalities related to chronic consumption of anabolic steroids.

Introduction:-
The detour of normal use or abuse of pharmacologically active substances has becomewidespreadamongathletes, and in addition to beingreprehensible, doping isdangerous for the whole body [1]. Anabolicandrogenicsteroids, includingtestosterone and itsmanymodifiedderivatives, remain the main substances detected in anti-doping tests and are generallyused to increaseathletic performance [2], an American studyindicated that more than one million Americans are users of anabolicsteroids [3]. The mechanisms of theircardiovascular complications are multiple: hydrosaline retention; vasoconstriction; bloodhyperviscosity; sympathetic stimulation; lipiddisorders; myocardial damage, [4,5,6 ].
We report the case of a young 24 yearoldhighlevelathletewho consumes anabolicproducts to increasehisathletic performance.

Clinicalobservation:
We report the observation of a 24-year-old high-levelathletewhoreported palpitations occurring atrest as well as duringexercise and who, on questioning, confessed to consumingandrogenicanabolicsteroids (testosterone injection).
The patient'sclinicalexaminationwasunremarkable, the ECG showed right delay-type VSEs, and the transthoracicechocardiographyshowed a dilated LV end-diastolicdiameter of 62 mm, normal leftventriculardiastolicfunction and a leftventricularejection fraction of 53% SB. A Holter ECG performed in this patient showedlown stage IV ventricularhyperexcitability.
An MRI performed to complete the workuprevealed on the Tappingsequences an alteration of the intrinsiccontractility in the anterolateralwall as well as a latesubepicardialenhancement in a band at the level of the septum extended to the anterolateralwall (Figure 1 and 2) revealingmyocardialfibrosis.

Discussion:-
Although the causal linkcannotbeestablished, this observation highlights the sideeffects of excessive use of anabolicsteroids.
Anabolicsteroidswereoriginallyusedtherapeutically in certain endocrine and neoplasticdiseases (6). The detour of their use to improveathletic performance is not withoutconsequences (5). Indeed, severalstudies have evaluated the cardiovascular complications associatedwith the use of these substances.
The secondarycardiovasculareffectsassociatedwithchronic use of androgenicanabolicsteroids are numerous:

Leftventricularhypertrophy :
Steroidscan cause leftventricularhypertrophy. This isrelated to the direct effect of testosteronewhichincreases muscle mass (2). This was not noted in our patient, neither on ECG nor on cardiacimaging (TTE and MRI). Nottin S et al alsoreported the absence of LVH related to the use of anabolicproductsin 6 highlevelathletes (7).

Myocardialinfarction :
Several cases of myocardialinfarction and suddendeath in younganabolicsteroidusers have been reported (8). In some cases, the coronaryarterieswere free of atherosclerotic plaques (9, 10). The cause ismultifactorial, already the increasedoxygendemand, caused by hypertrophy of the heart muscle, in addition to presenting an increasedrisk of vasospasm and a state of hypercoagulability.

Rhytmdisorders :
Rhythmdisordersat the supraventricular or ventricularlevel, whichcan go as far as VF reported by Lichtenfeld (11), whichissecondary to the direct toxicity of these doping products on the myocytes (5). Theserhythmdisorderswouldberelated to myocardialfibrosis. In our patient, the ECG showedseveralESVs of the right delay type.

Cardiomyopathies:
Leftventricular dilatation: as demonstrated in the series of Nottin S (7) and Chung T where the LV diameter increasedafterintramuscular injection of 200 mg testosterone per week for 4 weeks (12). LV dilatation wasalsonoted in our patient.
On the other hand, thereissomeevidencethatathleteswho use anabolicsteroids are atincreasedrisk of developingsystolic and diastolicdysfunction (13). Chung T notedasignificantincrease in LV filling pressures whencomparing a group of patients usingtestosterone and a group of patients receiving placebo (12). In the samestudy, LVEF wasalsosignificantlyimpaired in the group of patients receivingtestosterone.
In our patient the diastolicfunctionwas normal and the LVEF on MRI wasestimatedat 55% and the MRI showed on the Tappingsequences an alteration of the intrinsiccontractilityat the anterolateralwall.

Dyslipidemia :
The change in lipid profile in the consumer leads to vascularwall damage by promoting the inflammatoryprocess in the arterialwall. Steroids cause an increase in LDL and a decrease in HDL rangingfrom 40 to 70% depending on the dose and type of steroidused (14).

Arterial hypertension :
The relationshipbetweensteroids and hypertension remainsunclear, but studies have shownthatsteroids cause endothelialdysfunction in the kidneywithincreasedfluidretention.

Conclusion:-
Anabolicsteroidscanalsobeusedtherapeutically as theycanbeused to enhance eathletic performance. However, manystudies have shownthat overdose has a hightoxicity on the cardiovascular system whichcanbe life threatening. Thus, thereis a need to increaseawarenessamong the general population about the harmfuleffect of usingthesesteroidswithoutamedical prescription.

Practical implications :
The criticalrole of healthprofessionals in informing the general population and athletes in particular about the lethaleffects of these substances Health care professionalstreatingyoung patients withcardiovascularproblemsshouldalways suspect concomitant use of anabolicsteroids.