Beyond anabolic steroids: cardiovascular collapse in the modern physique enhancement era

Modern bodybuilding and aesthetic physique sports have become increasingly associated with cardiovascular morbidity and sudden cardiac death. Although anabolic-androgenic steroids are frequently implicated in bodybuilding-associated cardiotoxicity, contemporary physique-enhancement practices commonly involve complex polypharmacy regimens including growth hormone, insulin, stimulants, thyroid hormones, and diuretics, often combined with extreme dehydration and electrolyte manipulation during contest preparation. This narrative review summarizes the current evidence regarding cardiovascular remodeling, cardiotoxicity, and sudden cardiac death in competitive bodybuilders. Chronic exposure to performance-enhancing substances may contribute to pathological left ventricular hypertrophy, myocardial fibrosis, endothelial dysfunction, thrombogenesis, dyslipidemia, autonomic imbalance, and electrical remodeling. In addition, acute stressors during “peak week,” including dehydration, stimulant use, and electrolyte disturbances, may trigger fatal arrhythmias or ischemic events in susceptible individuals. Autopsy and imaging studies have reported structural and functional cardiac abnormalities consistent with maladaptive remodeling, while recent epidemiological evidence suggests elevated mortality rates among professional bodybuilders. Overall, cardiovascular risk in modern bodybuilding appears to extend beyond isolated anabolic-androgenic steroid exposure and likely reflects a complex interaction between chronic myocardial injury, polypharmacy, metabolic instability, and extreme physiological manipulation practices. Increased cardiovascular awareness and individualized cardiovascular surveillance strategies may help identify high-risk individuals and potentially reduce cardiovascular morbidity and mortality in competitive bodybuilders.