Show Me the Bodies – Performance Enhancing Drugs and Cardiovascular Risk


by Mike Arnold

It seems like just yesterday, at the premiere of the movie Bigger, Stronger, Faster, that steroid-using bodybuilders were treated to number of reassuring comments from industry insiders, claiming that anabolic steroids had been grossly misrepresented in terms of health risk. Presented as innocent victims of a government-media driven witch hunt, the message was clear—steroids were a relatively safe, if not benign category of performance enhancers. While the above agencies certainly assisted in the dissemination of misinformation, thereby causing society’s perception of these drugs to further deteriorate, the bodybuilding community’s response—characterized by a near complete dismissal of risk—was equally injurious, serving only to damage the health and long-term credibility of its participants.

As time went by, one particular quote from the movie took on a life of its own, becoming a sort of catchphrase among those attempting to minimize the perceived health risks of their chosen lifestyle. Originally stated by John Romano, “Show me the bodies” was an interesting choice of words. A purely defensive comment, it was intended to draw attention to the fact that steroids are almost never listed as an official cause of death, while indirectly refuting the claim that they increase mortality. As a result, many bodybuilders were lulled into a false sense of security and further emboldened in their drug abuse.

This is flawed logic, though, as the only purpose of the “cause of death” section on a death certificate is to indicate the immediate, as well as the underlying cause(s) of death. For example, if someone dies of cardiac arrest, the immediate cause of death might be listed as acute myocardial infarction (i.e. heart attack), while the underlying cause of death might be listed as coronary artery disease (i.e. atherosclerosis). As we all know, there are numerous potential risk factors in the development of cardiovascular disease, such genetics, obesity, smoking, poor diet, etc. However, you will not find “He ate McDonald’s and Krispy Kreme every day for the last 20 years” listed as an official cause of death, as the coroner must be able to show evidence for his claims by pointing to a provable pathology (diagnosable conditions directly linked to the immediate cause of death), rather than relying on speculation, no matter how likely it might be.

Although much of the information presented below has been known by certain factions of the medical community for decades, science continues to reveal new and sobering information regarding the ill-effects of AAS on cardiovascular health. At this point, the evidence is clear—steroid use is a significant risk factor in the development of multiple cardiovascular conditions, many of which can lead to serious or life-threatening complications (i.e. heart failure, heart attack, stroke, etc). Given the sheer importance of keeping this bodily system in good working order, all bodybuilders should be educated regarding the basic risks involved, as it is critical first step in the prevention process.

Some of the more concerning side effects of AAS on the cardiovascular system are: increased blood pressure, dislipidaemia (altered lipid profile), cardiomyopathy (heart muscle disease/abnormality), left ventricular hypertrophy (a specific from of cardiomyopathy associated with increased mortality), elevated hematocrit/hemoglobin, enhanced platelet aggregation, and various heart valve issues. Of these, elevated blood pressure is probably the most insidious of the bunch, as it is easy to diagnose, but frequently asymptomatic. In addition to cardiovascular dysfunction, elevated blood pressure is also the #1 cause of kidney damage in bodybuilders worldwide.

When blood pressure is elevated, the heart must work harder to supply adequate blood to the body. This causes the heart muscle to thicken (hypertrophic cardiomyopathy), as it strives to compensate for the increased workload being placed upon it. Over time, the heart muscle weakens, its contractile force is diminished, and it may have difficulty relaxing. This prevents the heart from properly filling with blood, eventually culminating in heart failure. Heart failure is a serious condition characterized by the heart’s inability to pump an adequate supply of blood to the body, including the heart itself. If left unresolved, the end result is a heart attack.

In addition to increased blood pressure, AAS are also capable of causing cardiomyopathy via overstimulation of the androgen receptor (AR) in heart muscle. Unfortunately, AAS are not selective when it comes to AR stimulation. Rather than attaching solely to ARs within skeletal muscle (which is the goal of S.A.R.Ms), they circulate throughout the entire body, latching onto and activating any AR they come in contact with. As a muscle, the heart is receptive to AR induced growth stimulation in the same way that skeletal muscle is, although some have proposed that it may possess a comparatively lower degree of susceptibility. Regardless, steroids have been proven to induce significant cardiac hypertrophy, especially when combined with weight training.

There are three primary types of cardiomyopathy: restrictive, dilated, and hypertrophic. Of these, hypertrophic and dilated are the most common types experienced by AAS users. Frequently caused by elevated blood pressure and coronary artery disease (common side effects of AAS use), dilated cardiomyopathy usually begins in the left ventricle (the heart’s main pumping chamber) and then spreads to other areas of the heart. It is characterized by a stretching and thinning (i.e. dilation) of the heart muscle. This causes the inside of the chamber to enlarge, preventing it from contracting normally. This directly reduces cardiac output and overall blood flow to the body. If allowed to progress unchecked, the heart will continue to weaken, leading to other conditions such as heart failure, blood clots, valve issues, and heart attack/stroke.

Hypertrophic cardiomyopathy is defined as an abnormal thickening of the heart muscle (particularly the left ventricle) and can be caused by high blood pressure, AR receptor activation, and athletic training (especially intensive weight training). Many of the issues associated with this type of cardiomyopathy are precipitated by muscular dysfunction. This is because the heart muscle tends to stiffen as it grows, resulting in potentially severe mechanical-electrical disturbances similar to those encountered with restrictive cardiomyopathy. This includes heart failure, valve problems, blood clots, and even dilated cardiomyopathy. The end points are the same—heart attack, stroke, etc.

Most doctors agree that the most dangerous form of hypertrophic cardiomyopathy, and the one AAS users are most susceptible to, is left ventricular hypertrophy, otherwise known as LVH. In order to understand why it is so important to keep this chamber of the heart functioning properly, let’s take a brief look at its role in the cardiovascular system.

When the heart receives oxygen-rich blood from the lungs, the first place it goes is the left atrium, after which it moves to the left ventricle—the most powerful of all the heart’s chambers and the one responsible for maintaining circulation. This thick muscle needs to be able to perform intense contractions so that it can force blood to all parts of the body. As the heart’s prime mover, even moderate dysfunction can result in death, so it’s not surprising that LVH has received so much emphasis in steroid users. Unfortunately, left ventricle failure is a much more common cause of heart failure/heart attack than right ventricle failure. Furthermore, even when right-sided failure is experienced, it is usually caused by problems originating on the left. Because of this, LVH is strongly associated with an increased risk of cardiovascular morbidity and mortality across multiple disease states. Steroids are a strong risk factor in the development of this condition, with elevated blood pressure and an enhanced hypertrophic response to resistance exercise being significant risk factors.

Interestingly, not all steroids affect the left ventricle to the same degree, but research in this area is limited, leaving us to speculate as to which AAS may be more detrimental. However, it does appear that the stronger the androgen, the more likely it is to promote LVH. Research shows that when 5-AR inhibitors are administered to those with this condition, left ventricle size is reduced, suggesting a primary role of DHT in the development of LVH relative to testosterone. However, few bodybuilders utilize 5-AR inhibitors in combination with testosterone, negating any applicable benefit this research might provide. There is some good news, though. LVH appears to at least partially resolve itself upon discontinuation of the offending substance(s). Obviously, this doesn’t provide license for abuse, but it is somewhat encouraging for those who are already experiencing issues in this area.

Let’s look at just a few more steroid-induced cardiovascular conditions—dislipidaemia, increased red blood cell production, and enhanced platelet aggregation. Dislipidaemia (poor lipid values) is one of, if not the biggest predictor of atherosclerosis, while atherosclerosis is the #1 cause of heart attack in the United States. For those of you who are unaware, atherosclerosis is a narrowing of the blood vessels through plaque build-up. If the arteries supplying blood to the heart become blocked as a result of this build-up, the individual will suffer a heart attack. If this occurs in the brain, it is called a stroke. If it takes place in the lungs, it is a pulmonary embolism. Each of these cardiovascular events can result in death or severe, long-term impairment. Methylated AAS (typically administered in oral form) are extremely injurious to the lipid profile, making them a potentially potent accelerator of atherosclerosis. While non-methylated injectables are generally milder in this regard, they are by no means innocuous.

Steroids also increase the risk of blood clot in two ways—through an increase in red blood cell production (polycythemia) and enhanced platelet aggregation. In a nutshell, the more red blood cells (RBC’s) the body produces, the thicker the blood gets. If blood viscosity increases too much, blood flow is restricted, leading to a slower rate of circulation and increased clot risk. In order to avoid intravascular coagulation (clotting), the blood must remain in constant motion. If it slows down too much or stops, it will begin to clot. AAS also increase clot risk directly; by enhancing platelet aggregation (the clumping together of platelets in the blood). Depending on where a clot forms/lodges, it can cause a heart attack, stroke, pulmonary embolism, etc.

If this isn’t doesn’t sound bad enough, consider the fact that this is only a partial list of health problems attributable to steroid use. Add growth hormone and insulin into the mix and it only gets worse from there. The problem with many cardiovascular conditions is that they are generally slow to develop, taking years or even decades to reach full maturity and produce life-threatening/life-ending cardiovascular events. On top of that, many fail to take part in regular lab-work (which is necessary for diagnosing these problems in the first place), allowing them to sneak by undetected and continue doing damage unrestrained.

With such serious potential side effects, one could be forgiven for thinking that all bodybuilders are aware of them, yet experience has proven otherwise. When it comes right down to it, some bodybuilders just don’t want to know the truth, because it would force them to leave their comfort zone and take personal responsibility for their actions. Therefore, they choose to remain in ignorance/denial and when challenged regarding their use, they often try to confuse the issues by playing the blame game.

Basically, the blame game is played as follows. Rather than admitting to the well know health risks of AAS, some individuals argue that because there are so many other potential risk factors (diet, bodyweight, genetic propensities, recreational drug use, etc) involved in the development of these conditions, that it is impossible to determine with any certainty the degree to which AAS play a role in their development. This leaves the door open for them to point the finger at non-PED risk factors as a primary cause of cardiovascular health problems in bodybuilders. While it would be foolish to discount the relevance of any risk factor, the presence of one risk factor does not eliminate another.

As mentioned previously, serious complications can often take years to manifest, which is why we are now seeing so many bodybuilders experience heart attacks and strokes in their 40’s, often long after they have retired from the sport. Given the fact that most dedicated bodybuilders live a lifestyle of regular weight training, cardiovascular exercise, and clean eating, such a trend should send up an immediate red flag, especially when considering the fact that non-drug using athletes who live a similar lifestyle aren’t succumbing to the same fate. In fact, they are most often at opposite end of the spectrum in terms of cardiovascular mortality.

Just last year, in my gym alone, there were three bodybuilders—all in their early-mid 40’s and with a history of long-term steroid use—who experienced heart attacks. To my knowledge, none of them used rec. drugs and all had been eating clean for over 20 years. Stories like this are becoming more and more prevalent, with many of my friends/acquaintances revealing similar happenings around the world. Although the bodybuilding lifestyle will always come with risks, we don’t have to blindly accept them as part of the deal. We decide what we are willing to put up with, and there is much we can do to minimize the negative effects of this lifestyle on our health.

It’s now been 8 years since the challenge to “show me the bodies” was made. In the words of Dante Trudel, it appears “the bodies are now starting to pile up” and it is impossible to deny. Be smart. Educate yourself on both the risks and preventative measures available to you, and instead wondering how you ended up with a cane in your hand and physical restrictions normally reserved for someone 25 years your senior, you will still be doing the things you love without hindrance or unnecessary concern.