Cardiovascular Risks and Management in Patients with History of Anabolic Steroid Use

Initial Assessment and Risk Stratification

The American College of Cardiology recommends obtaining detailed AAS exposure history, including specific agents used, cumulative duration of use, dosages, route of administration, time since last use, and whether currently using, to assess cardiovascular risk 1
Patients with a history of AAS use should be screened for cardiovascular symptoms, including chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, palpitations, syncope, and lower extremity edema, as recommended by the American College of Cardiology 1
Blood pressure should be measured using proper technique to detect hypertension, which is common with chronic AAS use, according to the American Heart Association 2
A cardiac examination should be performed to assess for murmurs, irregular rhythm, jugular venous distension, and signs of heart failure, as recommended by the American College of Cardiology 1
The American Heart Association recommends examining for cushingoid features, including abdominal striae, which may indicate concurrent or past corticosteroid use 2

Fasting glucose and hemoglobin A1c should be assessed to evaluate for glucose intolerance and diabetes mellitus, which are associated with AAS use, according to the American Heart Association 2
A complete blood count should be performed to assess for polycythemia, as recommended by the American Heart Association 2
Testosterone level should be determined to assess for hypogonadism, which is a common side effect of AAS use, according to the American Urological Association 3
Urinalysis with dipstick for proteinuria should be performed to screen for renal disease, as recommended by the American Heart Association 2
A 12-lead ECG should be performed to assess for left ventricular hypertrophy, conduction abnormalities, and arrhythmias, according to the American College of Cardiology and the American Heart Association 1, 2

The American Heart Association recommends blood pressure control to target <130/80 mm Hg using ACE inhibitors or ARBs as first-line agents 2
Lifestyle modifications, including weight loss if overweight/obese, regular aerobic exercise, smoking cessation, and alcohol moderation, should be counseled, as recommended by the American Urological Association 3

If testosterone deficiency is confirmed, exogenous testosterone therapy should not be commenced for 3-6 months after last AAS use to allow recovery of endogenous production, according to the American Urological Association 3
For men desiring fertility, use of aromatase inhibitors, human chorionic gonadotropin, or selective estrogen receptor modulators rather than exogenous testosterone is recommended, as testosterone therapy interrupts spermatogenesis and causes oligospermia or azoospermia, according to the American Urological Association 3
Target testosterone levels should be in the middle tertile of normal range (450-600 ng/dL) if replacement therapy is eventually indicated, as recommended by the American Urological Association 3
Alkylated oral testosterone should never be prescribed due to hepatotoxicity risk, according to the American Urological Association 3

The American Heart Association recommends regular follow-up schedule, including every 3 months initially for cardiovascular risk factor monitoring (blood pressure, lipids, glucose) 2

Patients should be informed that cardiovascular risks persist even after AAS discontinuation, with structural cardiac changes and atherosclerotic burden potentially irreversible, and advised against resumption of AAS use under any circumstances, according to the American Urological Association 3
Fertility implications should be discussed if future conception is desired, as recovery of spermatogenesis may take 6-12 months or longer after cessation, according to the American Urological Association 3