How Do Performance Enhancing Drugs Affect Cardiovascular Health

By Aliza Hirsch,


Exercise has the power to confer extensive health benefits. However, at extreme levels, there are those athletes and competitors who are willing to sacrifice their wellbeing for the sake of improved performance. Despite the recent stricter enforcement of drug testing and punishment for drug use amongst competitive athletes, the use of performance enhancing drugs (PED) continues. More recently, PEDs are becoming popular amongst recreational athletes and exercisers, making their usage a public health concern.  This is particularly concerning due to the significant detrimental effects of taking these drugs, particularly on cardiovascular health.

According to the American Journal of Pediatrics1, a PED is defined as:

“Any substance taken in nonpharmacologic doses specifically for the purposes of improving sports performance. A substance should be considered performance enhancing if it benefits sports performance by increasing strength, power, speed, or endurance (ergogenic) or by altering body weight or body composition. Furthermore, substances that improve performance by causing changes in behavior, arousal level, and/or perception of pain should be considered performance enhancing.”

The term PED covers several classes of drugs. Some examples of commonly used prescription PED include oxygen-carrying modulators, oxygen dissociation curve modulators, anabolic agents, hormone modulators, and amphetamines.2 Commonly, PEDs are thought to greatly improve athletic performance; however, proper research on how they affect athletic performance is in short supply. This is partially due to the ethical considerations that researchers face when studying such a controversial substance abuse issue.3

The so-called ‘benefits’ of PED use are largely based on their ability to allow for increased training capacity coupled with decreased recovery periods. There are physiological differences in the effects of PED based on the type of drug being taken. Oxygen-carrying modulators and dissociation curve modulators, such as Erythropoietin and Cobalt, provide the body’s muscles with increased access to oxygen through various mechanisms including improving cardiac output and increasing blood-oxygen levels.2 For this reason, this class of drugs is particularly popular amongst endurance athletes. Anabolic agents are responsible for the majority of doping cases in athletes. 2 They are used for their capacity to increase muscle mass and strength while simultaneously reducing fat. 4,5

These drugs have been linked to lethal cardiovascular outcomes including myocardial infarction, stroke, arrhythmias, endocarditis (i.e. infection of the inner lining of the heart), left ventricular hypertrophy (i.e. thickening of the hearts left chamber), cardiomyopathy (i.e. diseases of heart muscle), and sudden cardiac death. 2,6 Specifically, abusing anabolic agents may increase blood pressure while at rest and exercising, and decrease high-density lipoprotein (HDL) levels. 7,8 These changes put the anabolic abuser at increased risk of experiencing the adverse outcomes previously listed.

Recently, researchers compared male recreational weight lifters between the ages of 34 and 54 who took anabolic-androgenic steroids (AAs) to those who did not. Weightlifters who took AAs were more likely to have increased levels of coronary plaque and decreased heart-pumping capacity.9 Another study indicated that bodybuilders with a history of AA abuse displayed significantly lower levels of HDL cholesterol, which is a known risk factor for cardiovascular disease. 10 Despite these alarming effects, it is quite common for athletes to combine several types of PEDs and the combinatory effects of these drugs are not well known.

It is important to note that although PED use amongst competitive athletes is concerning, the reported use of PED by recreational athletes is growing. Unlike competitive athletes, recreational athletes do not face stringent drug testing procedures. In one anonymous survey of recreational athletes, 208 out of 1398 (15%) of respondents indicated that they were currently using or had previously used substances banned by the world anti-doping agency. 11 Another 15% of respondents said they were interested in or planning on taking these substances. 11 Research also suggests that PED use amongst adolescents is on the rise. 12,13 Therefore, it is critical that youth are well informed on the detrimental risks of abusing these substances. If you suspect that someone you know might be abusing PED, some visible changes to look for include acne, hair loss, weight gain, facial hair growth in women, aggressive and violent behavior, and paranoia.14



  1. Gomez, J., & American Academy of Pediatrics Committee on Sports Medicine and Fitness. (January 01, 2005). Use of performance-enhancing substances. Pediatrics,115, 4, 1103-6.
  2. La, G. A., & Brosnan, M. J. (January 01, 2017). Cardiovascular Effects of Performance-Enhancing Drugs. Circulation, 135, 1, 89-99.
  3. Angell, P. J., Chester, N., Sculthorpe, N., Whyte, G., George, K., & Somauroo, J. (October 24, 2012). Performance enhancing drug abuse and cardiovascular risk in athletes: implications for the clinician. British Journal of Sports Medicine, 46.
  4. Bhasin, S., Storer, T. W., Berman, N., Callegari, C., Clevenger, B., Phillips, J., Bunnell, T. J., … Casaburi, R. (January 01, 1996). The effects of supraphysiologic doses of testosterone on muscle size and strength in normal men. The New England Journal of Medicine, 335, 1, 1-7.
  5. Forbes, G. B., Porta, C. R., Herr, B. E., & Griggs, R. C. (January 01, 1992). Sequence of changes in body composition induced by testosterone and reversal of changes after drug is stopped. Jama, 267, 3, 397-9.
  6. Golestani, R., Slart, R. H. J. A., Dullaart, R. P. F., Glaudemans, A. W. J. M., Zeebregts, C. J., Boersma, H. H., Tio, R. A., … Dierckx, R. A. J. O. (January 01, 2012). Adverse cardiovascular effects of anabolic steroids: pathophysiology imaging. European Journal of Clinical Investigation, 42, 7, 795-803.
  7. Hartgens, F., Rietjens, G., Keizer, H. A., Kuipers, H., & Wolffenbuttel, B. H. (January 01, 2004). Effects of androgenic-anabolic steroids on apolipoproteins and lipoprotein (a).British Journal of Sports Medicine, 38, 3, 253-9.
  8. Riebe, D., Fernhall, B.O.,, & Thompson, Paul D. (January 01, 2006). The blood pressure response to exercise in anabolic steroid users. Medicine & Science in Sports & Exercise, 24, 
  9. Baggish, A. L., Weiner, R. B., Kanayama, G., Hudson, J. I., Lu, M. T., Hoffmann, U., & Pope, H. G. J. (January 01, 2017). Cardiovascular Toxicity of Illicit Anabolic-Androgenic Steroid Use. Circulation, 135, 21, 1991-2002.
  10. Santora, L. J., Marin, J., Vangrow, J., Minegar, C., Robinson, M., Mora, J., & Friede, G. (January 01, 2006). Coronary calcification in body builders using anabolic steroids.Preventive Cardiology, 9, 4, 198-201.
  11. Bojsen-Møller J, Christiansen AV Use of performance- and image enhancing substances among recreational athletes: a quantitative analysis of inquiries submitted to the Danish anti-doping authorities. Scand J Med Sci Sports. 2010;20:861–867.
  12. Hoffman, J. R., Faigenbaum, A. D., Ratamess, N. A., Ross, R., Kang, J., & Tenenbaum, G. (January 01, 2008). Nutritional supplementation and anabolic steroid use in adolescents. Medicine and Science in Sports and Exercise, 40, 1, 15-24.
  13. The Partnership Attitude Tracking Study. 2013. Accessed August 8, 2016.
  14. Anabolic Steroids Symptoms and Warning Signs (2016). Accessed August 8, 2016.
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