Evaluating ECG Criteria for Diagnosing Left Ventricular Hypertrophy in Anabolic-Androgenic Steroid Users

Rang Abdullah; Astrid Bjørnebekk; Lisa E Hauger; Ingunn R Hullstein; Thor Edvardsen; Kristina Haugaa; Vibeke M Almaas

doi:10.1016/j.jacadv.2025.102499

Evaluating ECG Criteria for Diagnosing Left Ventricular Hypertrophy in Anabolic-Androgenic Steroid Users

JACC Adv. 2026 Jan 13;5(2):102499. doi: 10.1016/j.jacadv.2025.102499. Online ahead of print.

Authors

Rang Abdullah¹, Astrid Bjørnebekk², Lisa E Hauger³, Ingunn R Hullstein⁴, Thor Edvardsen⁵, Kristina Haugaa⁵, Vibeke M Almaas⁶

Affiliations

¹ University of Oslo, Oslo, Norway; ProCardio Center for Research Based Innovation, Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Anabolic Androgenic Steroid Research Group, Section for Clinical Addiction Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.
² Anabolic Androgenic Steroid Research Group, Section for Clinical Addiction Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway.
³ The National Centre for Epilepsy, Division of Clinical Neuroscience, Full Member of European Reference Network on Rare and Complex Epilepsies EpiCARE, Oslo University Hospital, Oslo, Norway.
⁴ Norwegian Doping Control Laboratory, Department of Pharmacology, Oslo University Hospital, Oslo, Norway.
⁵ University of Oslo, Oslo, Norway; ProCardio Center for Research Based Innovation, Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
⁶ ProCardio Center for Research Based Innovation, Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway. Electronic address: vibalm@ous-hf.no.

Abstract

Background: Anabolic-androgenic steroid (AAS) users represent a high-risk cardiovascular population. Left ventricular (LV) hypertrophy (LVH) is a common complication, yet the utility of electrocardiographic (ECG) criteria for detecting LVH remains unexplored.

Objectives: The objective of the study was to evaluate the diagnostic performance of six commonly used ECG-LVH criteria in identifying echocardiographic LVH among long-term AAS users.

Methods: We included 100 male AAS users, 32 with echocardiographic LVH and 68 without. Six ECG-LVH criteria (Sokolow-Lyon, Modified Sokolow-Lyon, Cornell voltage, Cornell product, Peguero-Lo Presti, and Romhilt-Estes) were assessed for sensitivity, specificity, and predictive values, using echocardiography as the reference standard. LV systolic function was evaluated by LV ejection fraction and global longitudinal strain.

Results: AAS users with echocardiographic LVH exhibited more pronounced LV systolic dysfunction than those without, as shown by a higher number of individuals with LV ejection fraction ≤40% (7 [23%] vs 4 [6%], P = 0.02) and more impaired LV global longitudinal strain (-14.7% ± 2.7% vs -16.5% ± 2.2%, P = 0.002). Among voltage-based indices, Peguero-Lo Presti provided the best balance between sensitivity (31%) and specificity (88%). The point-based Romhilt-Estes using a cutoff of 5 offered comparable performance, with a sensitivity of 34% and specificity of 85%. However, most AAS users with echocardiographic LVH were not identified by ECG, with 69% remaining undetected by Peguero-Lo-Presti and 66% by Romhilt-Estes.

Conclusions: ECG was insufficient for identifying echocardiographic LVH in AAS users who represent a high-risk cardiovascular population. Routine specialist evaluations, including echocardiography, should be considered for long-term AAS users to facilitate early detection of LVH and associated dysfunctions.

Keywords: ECG; anabolic-androgenic steroids; left ventricular hypertrophy.