Cardiovascular risk profile, symptoms, and performance-enhancing drug use among competitive bodybuilders: insights from a national cross-sectional survey

Abstract Competitive bodybuilding combines high-intensity resistance training with frequent use of performance-enhancing substances and extreme weight manipulation. These practices may increase cardiovascular risk, yet real-world evidence in this athletic population are limited. Purpose To describe cardiovascular risk factors, cardiopulmonary symptoms, and performance-enhancing drug and weight-cutting behaviours in a national cohort of competitive bodybuilders. Methods An anonymous online survey was distributed to active competitive bodybuilders via a national federation. The questionnaire assessed anthropometry, training exposure, cardiovascular history, warning symptoms, prior cardiac investigations, use of performance-enhancing drugs (including anabolic-androgenic steroids and stimulants), and weight-cutting practices. Data were analysed using descriptive statistics. Results Fifty-one athletes completed the survey. Mean height was 171 cm and mean body mass index 25.6 kg/m². Participants reported a median of 5 training days/week, with approximately 350 minutes/week of resistance training and 150 minutes/week of cardio. A positive family history of premature cardiovascular disease and of sudden unexplained death in apparently healthy relatives were each reported by 6% of respondents. No athlete reported a known cardiovascular diagnosis; however, 10% experienced at least one cardiopulmonary warning symptom, including syncope, presyncope, palpitations, exertional chest discomfort, or disproportionate dyspnoea. Regular weight-cutting practices were common: 46% reported frequent or occasional cycles involving dehydration, diuretics or severe dietary restriction, and 11% reported the use of specific substances for rapid weight loss. Regarding performance-enhancing 61% used stimulant-containing pre-workout formulations, and 54% consumed caffeine-based stimulants or energy drinks regularly. Conclusions Despite the absence of diagnosed cardiovascular disease, competitive bodybuilders reported a meaningful burden of cardiopulmonary warning symptoms, a non-negligible family history of premature events, and high exposure to performance-enhancing drugs and extreme weight-cutting strategies. These findings highlight the need for targeted cardiovascular screening, structured risk stratification, and educational interventions promoting safer training and supplement practices in strength athletes.