A 24-year-old male bodybuilder presented with cardiac symptoms following long-term performance-enhancing drug (PED) use. He was diagnosed with heart failure with reduced ejection fraction and body dysmorphic disorder. Treatment included cardiac medical therapy and psychiatric support. After PED discontinuation and ongoing psychological care, symptoms improved and relapse was prevented. This case highlights the potential severe cardiovascular consequences of PED abuse in young, healthy individuals. It emphasises the importance of early recognition, multidisciplinary intervention addressing both physical and psychological aspects, and increased awareness about PED risks, particularly among those with body image disorders.
Introduction
Performance-enhancing drug (PED) use is a growing concern in physique-focused sports. While cardiovascular risks are known, severe heart failure in young, healthy individuals is rare. PED use is often driven by competitive desires and body image issues, frequently linked to disorders like body dysmorphic disorder (BDD). This case report details a young bodybuilder with newly diagnosed BDD who developed severe heart failure from long-term PED abuse. It emphasises the potential cardiovascular risks in seemingly healthy individuals and the need for early, multidisciplinary intervention addressing both physical and psychological aspects.
Case report
A 24-year-old male bodybuilder presented to the emergency department (ED) with palpitations, dizziness, nausea, vomiting and shortness of breath after a gym workout. He had no prior medical or psychiatric history, no family history of cardiovascular disease, and denied smoking and alcohol or recreational drug use. The patient, a former professional league rugby player, reported unlimited exercise tolerance and worked as a dog-walker.
On arrival to ED, his vital signs were as follows: oxygen saturations via pulse oximetry, 98% on ambient air; respiratory rate, 16 breaths per minute; blood pressure, 146/89 mmHg; heart rate, 186 beats per minute; blood glucose, 4.1 mmol/L and temperature, 38.7° Celsius. Systemic examination revealed jugular venous distension, pulmonary rales and normal heart sounds. There was no acne, testicular atrophy or peripheral pitting oedema. The patient weighed 95 kg with a height of 187 cm.
Infection and inflammatory markers, urea and electrolytes, thyroid function tests and liver function tests were all within normal limits. His HbA1C was 38 mmol/mol (normal: <42 mmol/mol), magnesium was 0.66 nmol/L (reference range: 0.7 – 1.0 nmol/L) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) was 3,443 ng/L (normal: <400 ng/L). The chest X-ray showed a small patchy consolidation in the right mid-zone. The admission electrocardiogram (ECG) showed atrial fibrillation (AF) with a rapid ventricular rate.
He confirmed that he was taking a cocktail of performance-enhancing drugs (PEDs), using a ‘blasting-then-cruising’ regime (tables 1 and 2), to prepare for bodybuilding contests. He would spend about six months either ‘blasting’ or ‘cruising’ and had obtained the drugs online from different websites.
Table 1. Blasting regimen
| Substance name | Concentration, dose, route and frequency |
| Testosterone | 0.3 mL (200 mg/mL), intramuscular, once weekly |
| Nandrolone (Deca-Durabolin) | 0.3 mL (unknown concentration), intramuscular, once weekly |
| Oxandrolone (Anavar) | 1 tablet (unknown concentration), orally, twice weekly |
| Clenbuterol | 1 tablet (unknown concentration), orally, weekly |
| Growth hormone | Unknown dose and concentration, intramuscular, once weekly |
Table 2. Cruising regimen
| Substance name | Concentration, dose, route and frequency |
| Testosterone | 0.25 mL (200 mg/mL), intramuscular, twice weekly |
| Tamoxifen | 1 tablet (unknown concentration), orally, twice weekly |
| Anastrozole (Arimidex) | 1 tablet (unknown concentration), orally, twice weekly |
In the ED, the patient received bisoprolol 1.25 mg once daily, intravenous (IV) magnesium 2 g/8 mmoL over 20 minutes once only, IV 0.9% sodium chloride 1000 mL over 8 hours, and oral co-amoxiclav 625 mg three times daily, for 5 days, for a chest infection. Echocardiogram showed severely impaired left ventricular systolic function (left ventricular ejection fraction, 27%). The heart failure team initiated dapagliflozin 10 mg once daily, furosemide 40 mg once daily, and ramipril 1.25 mg once daily. Bisoprolol was increased from 1.25 mg to 2.5 mg once daily due to non-sustained ventricular tachycardia, and apixaban 5 mg twice daily started for AF. The patient remained asymptomatic and was cardiologically optimised. The endocrinology multidisciplinary team recommended outpatient follow-up and psychiatric referral.
During hospitalisation, the patient underwent a comprehensive psychiatric evaluation. This assessment revealed a history of childhood trauma and confirmed a diagnosis of BDD based on DSM-V (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) criteria. Upon discharge, the patient’s heart rate had stabilised to approximately 110 beats per minute. He was referred to local community drug addiction services and outpatient psychiatric care for ongoing management of his BDD.
Two months after discharge, the patient reported at follow-up that he had stopped all PEDs, maintained medication compliance and engaged with outpatient psychiatric services. These interventions helped him to cope with his diagnoses and significantly improved his symptoms. He was referred for outpatient AF cardioversion and started on eplerenone 25 mg once daily.
Discussion
This case highlights the severe cardiovascular effects of PEDs in young, healthy individuals.1–3 The rapid onset of heart failure with complex arrhythmias in our patient contrasts with the gradual progression typical in older populations. The specific PED combination likely accelerated cardiomyopathy development, exacerbated by unknown concentrations in unregulated online-sourced drugs.4,5
Crucially, this case underscores the relationship between PED abuse and BDD. Our patient’s BDD diagnosis aligns with findings that 32% of anabolic steroid users have BDD.6–8 This psychological aspect presented unique management challenges, including balancing cardiac medications with the desire to maintain muscle mass.9
The multidisciplinary approach involving cardiology, endocrinology, and psychiatry was pivotal in addressing both physical and psychological aspects, leading to improved symptoms and medication compliance. This holistic strategy highlights the importance of integrated care in complex cases.10
Clinicians should consider targeted screening for PED use in young patients with cardiac symptoms, particularly those involved in bodybuilding. Long-term multidisciplinary follow-up is crucial for monitoring cardiac function and preventing relapse in former PED users.
Key messages
- Performance-enhancing drug (PED) abuse can cause severe cardiovascular complications in young, healthy individuals
- Underlying psychological disorders often contribute to PED use and require attention
- Effective treatment demands a multidisciplinary approach with early intervention and education.
Statement of consent
Written consent has been obtained from the patient for publication of the details of their medical case and the accompanying images.
Conflicts of interest
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References
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