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Try out PMC Labs and tell us what you think. Learn More. Anabolic androgenic steroids AAS have several adverse effects on the cardiovascular system that may lead to a sudden cardiac death SCD. The body showed hypertrophy of skeletal musculature, with low amount of subcutaneous fat and no s of injury body mass index, BMI: Areas of scarring were located at the intersection between the posterior wall and the posterior third of the septum postero-septal.
At histology, acute myocardial infarction at the anterior third Died from steroids the septum and the anterior wall, and subacute myocardial infarction at apical septum and apical posterior wall were detected. Other findings were small intramyocardial vessel disease and myocytes hypertrophy. Chemicotoxicological analysis in blood showed ethanol 0.
When confronted with a sudden death in a young athlete we must pay attention to the physical phenotype that may suggest AAS abuse and perform a detailed examination of the heart. Anabolic androgenic steroids AAS are synthetic testosterone derivatives developed to increase strength and muscle mass anabolic activity and minimize androgenic activity [ 12 ]. AAS are used in clinical setting to counteract the several side effects on the treatment of several illnesses, such as osteoporosis, aplastic anemia, and hypogonadism among others, and cachexia-associated conditions as burns [ 3 ], HIV [ 4 ], renal and hepatic failure [ 56 ], and cancer [ 7 ].
The use of these agents has spread from athletes and body builders to adolescents and adults with the aim to enhance muscular development and athletic performance [ 89 ]. Illicit AAS use began to emerge in the s in American population [ 10 ]. An estimated 2. About 1 million of individuals, most of them males, have developed AAS dependence, often leading to years of chronic AAS exposure [ 1213 ]. AAS have several adverse effects on the cardiovascular system: lipoprotein disorder, thrombosis, vasospasm, hypertension, cardiac hypertrophy, heart failure, arrhythmia, and sudden cardiac death SCD [ 19 ].
We present the case of a young male, AAS abuser with intramuscular delivery in the 6 months before, who died suddenly at home, describing the gross and microscopical findings at forensic autopsy, and toxicological. The effects of AAS on the cardiovascular system are also reviewed.
A year-old male suffered a cardiorespiratory arrest at home's bathtub when returning from New Year's party. Cardiopulmonary resuscitation was unsuccessful and a forensic autopsy was ordered by the Magistrate on duty. According to the deceased's friends, he had taken AAS stanozolol, testosterone, tamoxifen, mesterolone, and Died from steroids with intramuscular delivery in the 6 months doses unknown.
He had no family history of dyslipidaemia, premature atherosclerosis or cardiac events except for one episode of precordial pain some months before. There were no antecedents of illicit drugs consumption. The corpse showed hypertrophy of skeletal musculature, with low amount of subcutaneous fat and several tattoos in shoulders, arms, thighs, and thorax Figure 1. On internal examination, there were multiorgan congestion and acute pulmonary edema.
Mechanical trauma or asphyxia was ruled out. Hypertrophy of skeletal musculature and tattoos in shoulder, arm, thorax Aand thigh B. The right and circumflex coronary arteries did not show alterations. Areas of scarring were located at the intersection between the posterior wall and the posterior third of the septum postero-septal Figure 2. Atrioventricular and sigmoid valves were normal. Acute myocardial infarction at the anterior third of the septum and the left ventricle LV anterior wall Figure 4subacute myocardial infarction at apical septum and apical posterior LV wall Figure 5myocytes hypertrophy Figure 6 and small intramyocardial vessel disease Figure 7 were detected.
Furthermore, the macroscopic findings described in the coronary arteries were confirmed Figure 8. The rest of organs showed congestion and acute pulmonary edema. Macroscopic examination of the heart: areas of scarring located at the intersection between the posterior wall and the posterior third of the septum postero-septal. Macroscopic examination of the coronary arteries: severe atherosclerosis with acute occlusive thrombosis at the left main trunk and left anterior descendant. Analysis of anabolic steroids in whole blood was performed using a method ly developed by Fabresse et al.
Ethanol was positive in blood 0. Blood and vitreous humor were submitted to Died from steroids toxicological analysis by solid phase extraction SPE. The pH of each sample 2. The elutes were collected and evaporated to dryness under a gentle nitrogen stream. The upper organic layer was decanted into another tube and evaporated to dryness under a nitrogen steam. A six-point calibration curve was used over the range 1.
The mobile phase was composed of solvents A aqueous 0. Compounds were detected using an Orbitrap mass spectrometer Q-Exactive Focus; Thermo Scientific equipped with a heated electrospray ionization source HESI operating in positive ionization mode Sheath gas flow rate 60, Aux gas flow rate 5, Spray Voltaje 3. Chromatographic data acquisition and quantification were performed using TraceFinder Forensic v4. No interferences were observed at the retention times. The method showed a good linearity in the range ly described in physiological serum. The from the analysis of those anabolic steroids in blood are summarized in Table 1.
Tamoxifen and mesterolone were not found and testosterone was below quantification level. The cause of death in this young male was myocardial infarction with severe coronary atherosclerosis and acute occlusive thrombosis affecting left main trunk and LAD single vessel disease secondary to AAS consumption.
Personal antecedents and chemicotoxicological analyses excluded the presence of any other drugs of abuse. He had no family history of dyslipidaemia, premature atherosclerosis, or cardiac events. Cardiovascular effects of AAS described in case reports are mainly related with acute myocardial infarction due to premature atherosclerosis. Myocardial infarction without ificant coronary atherosclerotic disease has also been reported [ 923—26 ]. Other adverse cardiovascular effects such as left ventricular hypertrophy, impaired left ventricular function, arterial thrombosis, and pulmonary embolism have been described [ 9162327—31 ].
The most typical myocardial abnormality in AAS abusers is left ventricular hypertrophy, associated Died from steroids fibrosis and Died from steroids [ 89 ]. Acute non-fatal myocardial infarction was first reported in  and fatal myocardial infarction in .
Up until today, 19 fatal cases Melchert and Welder [ 40 ] suggested that there are at least four hypothetical models of ASS-induced adverse cardiovascular effects: atherogenic, thrombosis, vasospasm, and direct myocardial injury. The changes in lipid metabolism and lipoprotein levels increase the risk of atherosclerosis; polycythemia and enhanced platelet aggregation increase the risk of thrombus formation, and arterial vasospasm increases the risk of ischemia and the occurrence of infarction [ 61941 ].
Adverse effects of AAS on the diastolic and systolic function are probably due also to direct toxicity on myocardial structure apoptosis with increased collagen deposition, fibrosis, altered microcirculation with intimal hyperplasia of the intramural coronary arteries resulting in chronic ischemic damage [ 9 ]. Vascular endothelial cells may be directly affected by AAS, which may result in vasospasm [ 40 ].
Some authors have proposed that at physiological doses of testosterone, androgen receptors are saturated and the anabolic effects of supra-physiological doses of AAS occur via interaction of these synthetic androgens with glucocorticoid receptors [ 64243 ]. AAS have a low affinity for glucocorticoid receptors, but, at high concentrations, they can inhibit the binding of glucocorticoids and block their catabolic effects [ 64445 ]. Cardiovascular responses to AAS are due to specific myocardial receptors, which have transcriptional regulatory functions. The cardiac hypertrophy induced by AAS appears to be generated by a direct action on cardiac androgen receptors, whose effects are directly proportional to the dose, time and duration of drug administration [ 946—48 ].
The sympathetic nervous system involved in the neurological control of the cardiovascular system may be influenced by AAS when combined with exercise and confer an increased risk of life-threatening arrhythmias [ 1449 ]. According to Achar et al. This is important because GH may lead to cardiomyopathy, abnormal lipoprotein profiles [ 5152 ], and left ventricular hypertrophy [ 53 ]. Erythropoietin abuse is linked to hypertension and increased risk for thromboembolic events [ 54 ].
These effects may be difficult to separate from the of AAS abuse alone and motivate the further need for more rigorous clinical and forensic screening. We are in agreement with other authors in the consideration that nowadays AAS abuse is a public health issue because of self-administration that is particularly widespread among no-athletes at fitness centers with aesthetics goals [ 6285556 ]. When confronted with a sudden death in a young athlete we must pay attention to the physical phenotype such as muscular hypertrophy, striae in pectoral or biceps muscle, gynecomastia, testicular atrophy, and acne that may suggest AAS abuse and perform a detailed examination of the heart.
All authors gave final approval for publications. Lucena takes full responsibility for the whole work and the decision to submit and publish the manuscript. The Died from steroids was performed in compliance with the policies of research and ethical boards for postmortem studies performed at the Institute of Legal Medicine and Forensic Sciences of Las Palmas and Seville, and the National Institute of Toxicology and Forensic Sciences of Tenerife. This article does not contain any studies involving human participants performed by any of the authors.
Spanish legislation does not require written informed consent from the next of kin for the use of forensic autopsies in scientific publications. National Center for Biotechnology InformationU. Journal List Forensic Sci Res v. Forensic Sci Res. Published online Aug Lucena d. Author information Article notes Copyright and information Disclaimer. Received Nov 29; Accepted Mar This article has been cited by other articles in PMC. Abstract Anabolic androgenic steroids AAS have several adverse effects on the cardiovascular system that may lead to a sudden cardiac death SCD. Keywords: Forensic sciences, forensic pathology, anabolic androgenic steroids AASsudden cardiac death, autopsy, cardiac pathology, toxicology.
Introduction Anabolic androgenic steroids AAS are synthetic testosterone derivatives developed to increase strength and muscle mass anabolic activity and minimize androgenic activity [ 12 ]. Case report A year-old male suffered a cardiorespiratory arrest at home's bathtub when returning from New Year's party. Open in a separate window. Figure 1. Figure 2. Figure 3. Figure 4. Figure 5. Figure 6. Figure 7. Figure 8. No toxic substances were found in this routinely analysis. Table 1. of anabolic steroids determination. Discussion The cause of death in this young male was myocardial infarction with severe coronary atherosclerosis and acute occlusive thrombosis affecting left main trunk and LAD single vessel disease secondary to AAS consumption.
Conclusion When confronted with a sudden death in a young athlete we must pay attention to the physical phenotype such as muscular hypertrophy, striae in pectoral or biceps muscle, gynecomastia, testicular atrophy, and acne that may suggest AAS abuse and perform a detailed examination of the heart.
Compliance with ethical standards The investigation was performed in compliance with the Died from steroids of research and ethical boards for postmortem studies performed at the Institute of Legal Medicine and Forensic Sciences of Las Palmas and Seville, and the National Institute of Toxicology and Forensic Sciences of Tenerife.
Disclosure statement The authors declare that they have no conflict of interest. References 1. Evans NA. Current concepts in anabolic-androgenic steroids.Died from steroids
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Sudden cardiac death in anabolic androgenic steroids abuse: case report and literature review