Fall of the Titans

BACKGROUND: The use of nonprescription anabolic-androgenic steroids in bodybuilding is a growing concern due to the potential of severe cardiovascular side effects. CASE PRESENTATION: A 35-year-old man presented with acute dyspnea. Echocardiogram revealed heart failure with a reduced ejection fraction of 25%. The patient had been abusing exogenous testosterone and aromatase inhibitors over the past year but denied long-term use of these agents. Given his young age, family history, and short period of anabolic-androgenic steroid use, genetic testing was performed to evaluate for possible explanations of his severe heart failure. A pathogenic titan truncating variant was identified explaining his dilated cardiomyopathy. CONCLUSIONS: This case underscores the potential cardiac risks associated with anabolic-androgenic steroid use and highlights the importance of genetic testing in unexplained cardiomyopathy. Early recognition and prompt initiation of guideline-directed medical therapy can help prevent further deterioration and inform risk stratification and long-term management. TAKE-HOME MESSAGE: This case highlights potential cardiovascular risk associated with supraphysiologic AAS exposure, particularly in the presence of an underlying genetic predisposition. Clinicians should consider toxin exposure and genetic predisposition in patients with unexplained cardiomyopathy.