Bicuspid aortic valve and androgenic-anabolic steroids use - a perfect storm?

Bicuspid aortic valve (BAV) is the most common congenital valvular heart disease. Anabolic-androgenic steroid (AAS) use among strength athletes has been associated with hypertension, left ventricular (LV) hypertrophy, myocardial fibrosis, and increased arterial stiffness. Whether current AAS use is associated with a more adverse cardiovascular phenotype in athletes with BAV is unknown. We therefore describe a cross-sectional, hypothesis-generating study. We report 15 consecutive adult male athletes with BAV evaluated in a sports cardiology clinic. Four strength athletes reported current AAS use. All patients underwent comprehensive cardiac magnetic resonance imaging including aortography and late gadolinium enhancement (LGE). Comparisons were descriptive. Compared with non-users, AAS users had higher median LVEDVi (163 vs. 118 ml/m2), lower median LVEF (51% vs. 62%), greater maximum LV wall thickness (median 16.5 vs. 12 mm), more severe aortic regurgitation (3/4 vs. 2/11) and more frequent hypertension (3/4 vs. 2/11). Non-ischemic LGE was present in 4/4 AAS users and 0/11 non-users. All AAS users and two of 11 non-users were referred for valve surgery because of severe valve disease. Maximum ascending aortic diameter was similar between groups. In this small referred series of athletes with BAV, current self-reported AAS use was associated with a more adverse cardiovascular phenotype at presentation. The cross-sectional design, small sample, incomplete exposure and training data, and confounding by valve severity preclude causal inference. These observations generate a clinically relevant hypothesis that AAS exposure may modify the phenotype of BAV and warrant confirmation in larger prospective longitudinal studies. Not applicable.