‘Sustaining masculinity’: a scoping review of anabolic androgenic steroid use by older males

Figures & data

Table 1. Search Strategy/Terms.

S1	TI “anabolic–androgenic steroid*” OR “anabolic steroid*” OR “anabolic androgenic steroid*” OR AB “anabolic–androgenic steroid*” OR “anabolic steroid*” OR “anabolic androgenic steroid*”
S2	TI “image and performance enhanc* drug*” OR “performance and image enhanc* drug*” OR “performance enhance* drug*” OR “performance enhance* substance*” OR AB “image and performance enhanc* drug*” OR “performance and image enhanc* drug*” OR “performance enhance* drug*” OR “performance enhance* substance*”
S3	TI "anabolic–androgenic steroid*” OR “anabolic steroid*” OR “anabolic androgenic steroid*" OR AB "anabolic–androgenic steroid*” OR “anabolic steroid*” OR “anabolic androgenic steroid*" AND TX “Boldenone” OR “Masteron” OR “Mesterolone” OR “Metandione” OR “Methandrostenolone” OR “Methenolone” OR “Nandrolone*” OR “Oxandrolone” OR “Oxymetholone” OR “Stanozolol” OR “Sustanon” OR “Testosterone*” OR “Trenbolone*”
S4	TI “image and performance enhanc* drug*” OR “performance and image enhanc* drug*” OR “performance enhance* drug*” OR “performance enhance* substance*” AND TX “Boldenone” OR “Masteron” OR “Mesterolone” OR “Metandione” OR “Methandrostenolone” OR “Methenolone” OR “Nandrolone*” OR “Oxandrolone” OR “Oxymetholone” OR “Stanozolol” OR “Sustanon” OR “Testosterone*” OR “Trenbolone*”
S5	S1 OR S2 OR S3 OR S4
S6	Limit to: English language, Human Studies

Table 2. Inclusion and exclusion criteria.

Inclusion Criteria	Exclusion Criteria
English articles. Articles that referred to male anabolic steroid use. Evidence of AAS use among males older than 40. Non-prescribed AAS Use	Articles in any language other than English. Animal studies. In-vitro studies. Prescribed AAS use.

Table 3. Charting of records.

Citation and Study Details^a	Country	General Findings of Journal Articles / Presentation of Clinical Case Reports	Findings of Older Men (>40years)
			Patterns and Motivations for Use	Adverse Effects Reported/Diagnosed	Conclusions
Ahlgrim and Guglin (2009). Anabolics and cardiomyopathy in a bodybuilder: case report and literature review. Clinical case report. Sample n = 1 Age = 41	USA	41-year-old bodybuilder with severe systolic dysfunction and Class IV heart failure despite maximal medical therapy two weeks prior. 23 years resistance training. Disclosed AAS use on first admission in 2007.	Patterns: Last used AAS (250mg test enanthate injected every 5th day for 6-week cycle) in 2008 (4years prior to presenting). Also used furosemide, spironolactone, and hydrochlorothiazide before competitions to lose weight. Motivations: For competitive BB: previously semi-professional, national class bodybuilder.	Severe systolic dysfunction and Class IV heart failure. Diagnosed with cardiomyopathy in 2006 which resolved in 2007. Presented in 2007 with breathlessness, fatigue, and dyspnoea, affecting his ability to carry out resistance training.	The patient’s cardiac failure was associated with the use of AAS and other IPEDs and continuing to carry out heavy resistance training after being diagnosed. This resulted in the patient being evaluated for a heart transplant.
Ahmed et al. (2019). Bodybuilding Gone Wrong: Anabolic Steroid Induced Cardiomyopathy. Clinical case report. Sample n = 1 Age = 48	USA	48-year-old male presented with shortness of breath, nausea, and abdominal bloating. He showed for high testosterone level 2607 ng/dl (normal 241–827). AAS induced cardiomyopathy was diagnosed. Disclosed AAS use on admission.	Patterns: Prescription testosterone supplementation for 5 years reported by patient; however, this was not closely monitored, and use was reportedly abused. Patient had concerns regarding cessation of AAS for fear of losing muscle mass. Motivations: To increase muscle mass.	Severe dilated cardiomyopathy, liver dysfunction and mood was affected.	He received psychosocial treatment to aid with his fear of losing muscle mass whilst not using AAS. He made a full recovery in one month.
Alibegović (2018). Testicular morphology in hypogonadotropic hypogonadism after the abuse of anabolic steroids. Forensic case report. Sample n = 1 deceased male. Age = 57	Slovenia	A case report of a man who committed suicide after a history of aggressive behaviour and reported physical abuse of his wife.	Patterns: Injected with AAS for an unspecified long period of time. He also consumed Cialis pills (tadalafil) for erectile dysfunction. Motivations: NR	The autopsy revealed secondary hypogonadism as a result of anabolic steroid abuse.	A more accurate analysis confirmed an overdose of AAS.
Baggish et al. (2017). Cardiovascular Toxicity of Illicit Anabolic-Androgenic Steroid Use. Journal Article. Quantitative. Observational study using a cross-sectional cohort design. Sample n = 86 weightlifters recruited at gyms. Age range = 39–47; Median age = 42; Age of first use = 19–30	USA	Age range 39–47 so including this paper in the older male AAS user category. This is the first controlled study to demonstrate that long-term AAS use is associated with systolic and diastolic myocardial dysfunction, and coronary atherosclerosis. Systolic function was found to recover on cessation of AAS but diastolic dysfunction was less reversible. Atherosclerotic disease strongly linked to lifetime use of AAS.	Patterns: Cumulative lifetime total duration of AAS use median 7.4 years. Cumulative lifetime dose of AAS, 166–608g (n = 366). Motivations: NR	Long-term use of AAS associated with myocardial dysfunction and accelerated coronary atherosclerosis.	Premature coronary artery disease and LV dysfunction associated with AAS use. Findings inform public health initiatives to control exposure to AAS and provide healthcare providers improve patient care.
Bates and McVeigh (2016). Image and Performance Enhancing Drugs 2015 Survey Results. Report Quantitative. Survey of IPED users recruited predominantly gyms and sports settings. Also, drug and health services, NSPs^b and on online forums. Sample n = 636; Age-range = 16–68; Mean = 30; Median = 29; Age of first use = 19–41+	UK	Study focused on all IPEDs. 65% reported both oral and injectable IPEDs. Most commonly used AAS reported was Deca Durabolin (38%), followed by testosterone enanthate & Sustanon. Polypharmacy of AAS and other IPEDs for oestrogen control, PCT, and fat loss reported. Motivations primarily for muscle enhancement, improve strength & fat loss. A minority of participants engaged with healthcare pertaining to adverse effects of AAS use.	Patterns: n = 18 initiated injecting AAS use over age 41. n = 8 initiated oral AAS use over age 41 years. Motivations: NR	NR	The findings highlight the importance of the need for IPED users to better engage with health services for the treatment of adverse health of IPED use. Effective identification and approaches to increase testing for blood borne viruses is warranted.
Begley et al. (2017). Image and Performance Enhancing Drugs: 2016 National Survey Results. Report. Quantitative. Survey of IPED users recruited at NSPs, harm reduction outreach, gyms and sports settings. Sample n = 643; Age-range = 17–74; Mean = 32; Median = 30; Age of first use = 14–53	Wales & England	AAS most commonly reported IPED used. 89% ever used oral IPEDs, 85% ever injected. Dianabol most commonly reported oral AAS, testosterone most reported injected AAS. Changing body image/aesthetics primary motivations for use. Adverse effects reported: testicular atrophy, sleep problems, libido changes, aggression, and acne. More than half would not seek medical advice.	Patterns: n = 26 initiated injecting AAS use over age 41;n = 20 initiated oral AAS use over age 41 years Motivations: NR	NR	They average person using IPEDs in the UK is likely to be a white British male, in their 30s using both orals and injectables (intramuscular) combined. Aesthetics primary motive for use.
Bonnecaze et al. (2020). Characteristics and Attitudes of Men Using Anabolic Androgenic Steroids (AAS): A Survey of 2385 Men. Journal Article. Quantitative; Survey of AAS users on online fora. Sample = 2385; Age-range = 18–51+; Mean = 31.69 + 10.09; Age of first use = 22–30.	Global	Testosterone enanthate, testosterone cypionate, metandione, trenbolone, oxandrolone, and nandrolone decanoate most reported AAS used. Motivations: To improve appearance and strength. Continued use due to fear of decreased quality of life, muscle loss, and decreased strength/athletic performance. Primary sourcing route was the internet. 56% had never disclosed their AAS use to healthcare provider (HCP) due to judgement, lack of confidence in physician knowledge, and legal repercussions. Adverse effects reported include testicular atrophy, acne, hypersexuality, hypertension, mood changes, erectile dysfunction, dyslipidaemia, and gynecomastia. Older males less likely to use illicit substances however Marijuana, alcohol, MDMA, amphetamines, psychedelics and cocaine were reported.	Patterns: 471 (20%) participants older than 40. 7% (n = 175) reported age of initiation older than 41 years of age. Motivations: [men older than 35]: to improve appearance/muscle (80%), improve strength (40%), self-esteem (20%), BB competitions (13%), athletics (8%), peer pressure (1%) and history of sexual abuse (<1%). Reason for not stopping/continued use [older than 35] fear of: decreased quality of life (60%), loss of muscle mass/appearance (40%), strength/athletic performance (35%), and lack of medical support (14%), withdrawal syndrome (11%) and addiction (5%). Males over 35 years old less likely to consider stopping AAS use than those younger.	Testicular atrophy, acne, hypersexuality, hypertension, mood changes, erectile dysfunction, dyslipidaemia, and gynecomastia reported. Older males were more likely than younger counterparts to report hair loss, tendon rupture, left ventricular hypertrophy, infertility, injection site abscess, and polycythaemia. Older males more likely than younger males to have diagnostic tests such as: prostate specific antigen (PSA) testing, coronary artery calcium scan, transthoracic echocardiogram and electrocardiogram.	Further research required to address the treatment of AAS use disorder. Healthcare professionals should be informed, non-judgemental and adopt a harm reduction approach to those who use AAS.
Boregowda et al. (2011). Persistent primary hypogonadism associated with anabolic steroid abuse. Clinical Case Report. Sample n = 1 Age = 40	Wales	40-year-old man with secondary gonadal failure resulting from anabolic steroid use with subsequent primary gonadal failure and infertility. Patient referred by his primary care physician to the local endocrine clinic with erectile dysfunction and infertility over the preceding 6 years. He and his partner had undergone infertility investigations.	Patterns: Over 10 years he administered nandrolone, T, and growth hormone He reported he had stopped taking anabolic steroids 2 years before seeking medical help Motivations: To promote muscle growth for bodybuilding.	He complained of low libido and erectile dysfunction since stopping anabolic steroid use and testicular atrophy. Thirty months after discontinuing anabolic steroids he had evidence of primary gonadal failure.	His erectile function improved with a phosphodiesterase-5 inhibitor. This case adds to the current literature and illustrates that the side effects of anabolic steroids can be prolonged and irreversible.
Cabb et al. (2016). The Diagnosis and Manifestations of Liver Injury Secondary to Off-Label Androgenic Anabolic Steroid Use. Clinical Case Report. Sample n = 1 Age = 45	USA	45-year-old male with progressive pruritus, jaundice, and scleral icterus for the past 2 weeks. Patient disclosed AAS use on admission.	Patterns: Man was taking AAS for the past 3 months (Anavar 50 mg daily and testosterone injections once weekly). He discontinued after the onset of symptoms. Motivations: NR	Pruritus, jaundice, and scleral icterus. Associated signs included pale stools and dark urine.	Suspected drug-induced liver injury. Two follow-up visits where a metabolic panel was repeated. The first visit, 4 days after hospital discharge, showed worsening laboratory values, although the patient’s overall history and physical examination expressed clinical improvement. On last contact with the patient, he reported complete resolution of signs and symptoms, and his liver function tests continued to improve.
Chandler and McVeigh (2014). Steroids and Image Enhancing Drugs; 2013 Survey Results. Report. Quantitative. Survey of IPED users recruited at NSPs. Sample n = 79; Age-range = 16–56; Mean = 32.5; Age of first use = .18–29	UK and Ireland	78.7% reported ever injecting AAS and 85% oral use. 85.1% reported ever used AAS. Other IPED use was reported and included growth hormone and insulin and DNP. 27 participants reported blast and cruise regime. Participants generally self-managed adverse effects themselves ad would not seek medical treatment.	Patterns: 6 initiated injecting AAS use over age 41 and 5 initiated oral AAS use over age 41 years. Motivations: NR	NR	Older experienced users (gender not specified) reported concerns for younger users IPED use regimes.
Christiansen et al. (2016). Outline of a typology of men’s use of anabolic androgenic steroids in fitness and strength training environments. Journal Article. Qualitative. Semi-structured interviews conducted for three different research projects, specific recruitment details not reported. Sample n = 37; Age-range = 21–42.	Global	The authors suggested an ideal typology as a new approach to studying the use of AAS in fitness and strength training environments. The typology consists of four types: the Expert type, the Well-being type, the YOLO type and the Athlete type. These represent four ideal-typical approaches to AAS use that emerge out of an analysis of users’ attitudes to risk and effectiveness.	Patterns: The well-being type typically uses lower dosages than the Athlete type and the Expert type. He possibly had his point of departure for AAS use in one of the other types before he was the. The well-being type is typically older than users in the other types. The well-being type considers the risks involved in using AAS and takes precautions by using PCTs to counter side effects. Motivations: For the well-being type: muscle mass and strength. Physical, mental and social well-being experienced from training and bodybuilding to achieve an appealing, fit-looking body was important and makes him feel younger and more self-assured.	NR	The Well-being type is generally the older male. The Well-being type bears resemblance to the typical AAS user described by Cohen et al. (2007).
Cohen et al. (2007). A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States. Journal Article. Quantitative. Survey of AAS users recruited on Online fora, Email and Postal. Sample n = 1955; Age-range = 18–76; Mean = 31; Median 29; Age of first use = 18+	USA	Increased muscle mass, increased strength and physical appearance primary motivations. Continued use was due to fear of losing muscle mass. Most commonly reported AAS used were single ester testosterones, methandrostenolone, and nandrolone decanoate. Injectable AAS preferred over orals. Most (66%) were willing to seek medical advice for AAS related issues and 61% obtained blood work at least once a year to assess the effects of AAS use on health.	Patterns: One participant-initiated use at 68 years old. Motivations: Older males motivated by fat loss.	NR	The study highlighted that most AAS users do so responsibly, by adopting safer routes of administration and hygienic injection practices, consuming a healthy diet, employing methods to reduce side effects, obtaining regular blood work, and periodically cycling on and off AAS.
Colburn et al. (2017). The cost of seeking an edge: Recurrent renal infarction in setting of recreational use of anabolic steroids. Clinical Case Report. Sample n = 1; Age = 43.	USA	43-yer-old Man with a past medical history of obsessive-compulsive disorder (OCD) and prior appendectomy. Presented with 2 days of left flank pain described as severe, sudden onset, sharp, constant, and without radiation. Reported medication was escitalopram 20mg. Pt was discharged same day with opioid analgesics. Patient returned the next day as pain had not ceased. Did not inform medical professionals of his AAS use on first hospital admission. Admitted AAS use on second admission.	Patterns: Patient revealed on the second visit to hospital that he had been using both testosterone and trenbolone acetate, intermittently over a period of 5 years, with last use 2 weeks prior to initial admission. Motivations: NR	Diagnosed with left renal parenchymal infarct and acute kidney injury (AKI). He was admitted and started on a continuous heparin drip for anticoagulation.	The patient experienced gradual improvement in pain and renal function. On hospital day 3, enoxaparin was started as a bridge to therapeutic INR on warfarin. He was discharged on hospital day 4, following stabilization of creatinine and acceptable pain control. Extensive counselling was provided regarding the risk of thromboembolic events with continued use of anabolic steroids.
Ding et al. (2013). Androgenic-anabolic steroid drug-induced liver injury. Clinical Case Report. Sample n = 1; Age = 46	Australia	A 46-year-old man present with jaundice and weight loss. Following liver biopsy, intrahepatic cholestasis and occasional necroinflammatory foci was reported. These are consistent with stanozolol use. Disclosed AAS use on admission.	Patterns: He had ingested stanozolol (40 mg) and methandrostenolone (40 mg) daily for 2 months and reported stopping usage 5 months prior to his initial symptoms. Motivations: NR	Nausea, pruritus, and anorexia	Patient was required to cease use of AAS for 5 months.
Farzam (2021). Anabolic-Androgenic Steroids and Cardiometabolic Derangements. Clinical Case Report. Sample n = 1; Age = 56.	USA	56-year-old male presented to the family medicine clinic for a general check-up for health maintenance. The patient had a blood pressure of 136/80. Disclosed AAS use on admission	Patterns: He first began using anabolic steroids over thirty years ago and cycled up until the day of admission. AAS used included trenbolone, nandrolone decanoate, methenolone, stanozolol (Winstrol), boldenone undecylenate (Equipoise), oxymetholone (Anadrol), metandienone (Dianabol), and fluoxymesterone (Halotesin). Use on admission was testosterone cypionate at 125 mg per week along with supplements including garlic tablets, tauroursodeoxycholic acid (TUDCA) at 500 mg daily, resveratrol, alpha-lipoic acid (ALA) at 600 mg daily, turmeric, vitamin C, fish oil at 3 grams daily, vitamin D at 5000 IU daily, coenzyme Q10, and n-acetyl cysteine (NAC) 1200 mg daily. Motivations: NR	Diagnosed with Type 2 Diabetes Mellitus diagnosis, hyperlipidaemia, borderline elevated blood pressure, and moderately elevated hs-CRP. Echocardiogram revealed mild left ventricular hypertrophy and mildly decreased right ventricular function.	The patient was placed on aspirin 81 mg daily. He was not willing to begin statin therapy and opted for major lifestyle modification and niacin therapy for his dyslipidaemia. He was also started on an angiotensin-converting enzyme (ACE) inhibitor at a low dose to aid in his left ventricular remodelling and better optimize his hypertension. This case highlights the potential need for extensive metabolic and cardiac evaluation in long term AAS users.
Fisler et al. (2018). Bile Cast Nephropathy: The Unknown Dangers of Online Shopping. Clinical Case Report. Sample n = 1; Age = 56.	Switzerland	A 56-year-old man presented in the emergency department due to painless icterus and severe pruritus. The clinical examination revealed hypertension bp 173/90; acute kidney injury and hyperbilirubinemia attributed to suspected drug use, finally revealed to be AAS. Did not disclose AAS use initially and was significantly ill with hepatotoxicity and jaundice by the time he did disclose AAS use history.	Patterns: Intramuscular use of propionate, testosterone acetate, dromostanolone propionate, and methyltrienolone. Motivations: to increase muscular mass for bodybuilding training.	Reduced urine volume and discoloration of the urine was reported on admission. Clinical examination revealed hypertension bp 173/90; acute kidney injury and hyperbilirubinemia attributed to ‘suspected drug use’. Anuric acute kidney failure developed while patient at hospital followed by further severe pruritus.	Patient required 4 weeks of dialysis to recover kidney function. Hyperbilirubinemia normalized over those weeks also.
Flo et al. (2018). Anabolic androgenic steroid-induced acute myocardial infarction with multiorgan failure. Clinical Case Report. Sample n = 1; Age = 41.	USA	A 41-year-old male fitness trainer presented with sudden onset chest pain at rest 3 hours prior to presentation. At presentation, the electrocardiograph was consistent with inferior ST segment myocardial infarction with a heart rate of 54 beats/min. Angiogram showed a totally occluded right coronary artery. Cardiac echocardiography demonstrated a severely dilated right atrium, right ventricle, and left atrium; a normal-sized left ventricle with moderate concentric left ventricular hypertrophy; and a severely reduced left ventricular ejection fraction of <20%. By hospital day 2, he developed worsening acute kidney injury, an abnormal coagulation profile, hyperbilirubinemia, and acute liver injury. Disclosed AAS use on admission.	Patterns: Use of AAS for >20 years in significant amounts. Motivations: NR	Based on assessments by a gastroenterologist and nephrologist, the patient had acute ischemic injury to both kidney and liver secondary to decreased cardiac output. The acute prothrombotic event which caused right coronary artery infarct, left ventricular dysfunction secondary to chronic dilated cardiomyopathy was attributed to abuse of AAS.	Thrombectomy and percutaneous coronary intervention with insertion of a drug-eluting stent were performed. He was given low-infusion-rate intravenous dextrose for the acute liver injury. Eight days after admission the patient showed improvement and was discharged in stable condition. Follow-up with cardiology, nephrology, and gastroenterology was arranged.
Gangadharamurthy et al. (2018). Anabolic Androgenic Steroid Abuse and Reversible Cardiomyopathy: An Emerging and Under-Recognized Cardiovascular Public Health Problem among Fitness Enthusiasts. Clinical Case Report. Sample n = 1; Age = 53	USA	A 53-year-old well-built muscular man and fitness trainer presented with left facial droop, left arm weakness and NYHA II symptoms (mild shortness of breath and/or angina, limitation during ordinary daily activity). Disclosed AAS use on admission.	Patterns: Using AAS for 20 years Motivations: NR	Cardiomyopathy was an incidental finding. Cardiac MR showed mid-myocardial enhancement consistent with nonischaemic cardiomyopathy. Erythrocytosis was reportedly due to AAS use.	Symptoms resolved with therapeutic phlebotomy, treatment of stroke and heart failure. The patient achieved near reversal of cardiomyopathy with continued therapy of heart failure and abstinence from AAS.
Graham et al. (2006). Homocysteine induced cardiovascular events: a consequence of long term anabolic-androgenic steroid (AAS) abuse. Journal Article. Cross-sectional quantitative study, collecting biomedical data with a control group. Recruited from a database of subjects who had been involved in previous studies, and from notices placed on bodybuilding web sites. Sample n = 40; Mean = 42.4 + 3.8.	UK	Biomedical data collection: Plasma concentrations of HCY, plasma folate, testosterone, sex hormone binding globulin (SHBG), free androgen index (FAI), urea, creatinine, haematocrit (HCT), and vitamin B12 (B12) were measured.	Patterns: NR Motivations: Competitive BB	Three individual subjects died suddenly during the study. They had elevated homocysteine levels greater than the SU group as a whole Their mean age (n = 3) was 43 years.	The findings suggest that the long-term use of supraphysiological doses of AAS are significant for hyperhomocysteinaemia and dramatically elevated HCT concentrations.
Hanley Santos and Coomber (2017). The risk environment of anabolic–androgenic steroid users in the UK: Examining motivations, practices and accounts of use. Journal Article. Qualitative. Semi-structured Interviews with IPED users, gym owners, and suppliers. Recruited from local safer injecting service through purposive and snowball sampling. Sample n = 22; Age-range = 20–44; Mean = 31; Age of first use = 16–38.	England.	Themes found: Motivations for use. Different pathways into steroid use. Patterns of use: managing risk (or not). Accounts of use: downplaying risk. Ambivalence and stopping steroid use. Patterns of steroid use by participants varied according to motivation for use, experience and knowledge gained. Participants differentiated themselves from other groups of steroid users—for example, older users. Participants older than 40 (n = 5)	Patterns: NR Motivations: To look good, nice physique in their 40s.	NR	Older users expressed concern over patterns of use of inexperienced younger AAS users as they believed they were engaging in riskier behaviours than themselves. Older participants also believed younger males are now using for aesthetics rather than serious bodybuilding which they felt was due to lack of knowledge on safe use of AAS. Conversely one older participant was engaging in continual steroid use without cycling.
Harvey et al. (2021). Libido as a motivator for starting and restarting non-prescribed anabolic androgenic steroid use among men: a mixed-methods study. Journal Article. Mixed methods. Questionnaires and semi-structured interviews with AAS users. Sample n = 133; Age-range = 18–65; Mean = 35.7; Age of first use = 14–57.	Global	74% reported improved quality as a result of uptake of AAS use. Motivations included muscle enhancement, appearance, enhance confidence, fitness, sex drive, and stamina. 90% reported re-starting AAS for the positive feelings associated with increased libido. Experiences of healthcare were positive for USA participants but negative for UK participants who felt physicians had a poor understanding and knowledge of the psychological effects of AAS use. Increased libido was reported by many as both a positive and negative effect of AAS use.	Patterns: One older male particiapant could access TRT (Testosterone Replacment Therapy) from his doctor. However, when he wanted to compete, he would top up with non-prescribed AAS. Motivations: Increased libido as a motivation for initiation and also re-starting AAS use. A desire to combat the effects of the natural aging process. Motivated to use to manage the negative effects such as moving away from using in cycles to instead using a ‘blast and cruise’ regime.	NR	One older male form the USA older male participant illustrated the benefits of healthcare access at private online clinic. The effects of aging, particularly the side effects of lowered testosterone, can impact men’s self-esteem regarding their sense of self and masculine identity and this could lead them to choose to self-medicate with AAS.
Havnes et al. (2019). Anabolic-androgenic steroid users receiving health-related information; health problems, motivations to quit and treatment desires. Journal Article. Quantitative; Cross-sectional prospective study. Users of AAS and next of kin who voluntarily contacted the Steroid Project for health-related information session from April 2015 to March 2019. Sample n = 232; Age-range = 16–67; Mean = 31.4; Age of first use = 19, 12–51.	Norway	77.2% desired treatment for AAS health related issues and cessation. 47.8% reported mental health problems as the primary motivation for AAS cessation.	Patterns: NR Motivations: NR	NR	Those who wanted to attend for treatment were significantly older.
Ilhan et al. (2010). Acute myocardial infarction and renal infarction in a bodybuilder using anabolic steroids. Clinical Case Report. Sample n = 1; Age = 41	Turkey	A 41-year-old male bodybuilder was admitted to the emergency service with chest pain of four-hour onset. Disclosed AAS use.	Patterns: Use of oxymetholone and methenolone for 15 years Motivations: For performance enhancement.	Chest pain. Primary percutaneous coronary intervention (PCI) was performed for a total occlusion localized proximal to the right coronary artery with a door-balloon time of 25 minutes.The patient was discharged on the 10th day on treatment with dual antiplatelet therapy and anti-ischemic drugs.	Medical history should be taken carefully with individuals who engage in bodybuilding or other performance sports with respect to possible AAS use to aid the prevention and early diagnosis of cardiovascular problems.
Ip et al. (2015). Characteristics and Behaviors of Older Male Anabolic Steroid Users. Journal Article. Quantitative; Cross-sectional survey of AAS users. Online bodybuilding, fitness, & AAS forum members. Sample n = 67; Age-range = 40–73; Mean = 47.3 ± 6.7; Age of first use = 17–69.	USA	Most Caucasian, heterosexual, recreational gym goers. Exercise patterns in the over 40-year-old were similar to those of AAS users in the general population. OMAAS more likely than nonusers to binge drink and partake in heavy alcohol use which is greater in comparison to current drinkers in the general older adult population.	Patterns: Used multiple PIEDs including agents to compensate for adverse effects. Used supraphysiologic doses of AAS. Weekly AAS dose, mg 1103.6 + 1165.6. Plan to use AAS in future (n = 57) Motivations: AAS users rated increase muscle mass, increase strength, and improve physical appearance as important/very important reasons for using AAS. They also ranked ‘‘slow the aging process’’ as somewhat important/important.	AAS users were more likely to report an anxiety disorder. DSM-IV-TR Psychiatric Diagnoses in OMAAS: Any psychiatric illnessd (n = 11) Anxiety disordere (n = 8) Major depressive disorder (n = 6 ) ADHD (n = 3)	The findings in this study can help clinicians and researchers better understand the older AAS-using population, which may lead to improved identification and potential interventions in the older male population.
Kimergard (2015). A qualitative study of anabolic steroid use amongst gym users in the United Kingdom: motives, beliefs and experiences. Journal Article. Qualitative; Semi-structured Interviews with AAS users. Recruited from fixed-site needle and syringe programmes; outreach service; steroid clinics; a gym; and a prison. Sample n = 24; Age-range = 21–61; Mean = 34; Age of first use = 16–25.	UK	Motivations for AAS use centred on improved physique, increased muscle strength and definition, anti-ageing. Other IPEDs used included Growth hormone and weight loss drugs. Many believed that AAS and IPEDs can be used safely and are part of a healthy lifestyle. Older than 40 (n = 5).	Motivations: To maintain appearance when getting older and combatting ageing	NR	The study of AAS users demonstrates the inconsistencies in the perception of the harms of AAS between users and health authorities, the media and policymakers which has implications for the promotion of public health.
Kimergard et al. (2014). Environments, risk and health harms: a qualitative investigation into the illicit use of anabolic steroids among people using harm reduction services in the UK. Journal Article. Qualitative; Semi-structured Interviews with AAS users. Recruited from fixed-site needle and syringe programmes; outreach service; steroid clinics; a gym; and a prison. Sample n = 24; Age-range = 21–61; Mean = 34; Age of first use = 16–25.	UK	Motivations for AAS use centred on body image enhancement.	Patterns: Older experienced user reported concerns for younger users IPED use regimes and acted as mediators and recommended advice regarding cycles, dosages and also recommended that young users not use until they are older. Motivations: NR	NR	Consideration of situational and environmental factors for the potential harms from AAS use are significant for public health strategies and the promotion and protection of health.
Kovac et al. (2015). Men regret anabolic steroid use due to a lack of comprehension regarding the consequences on future fertility. Journal Article. Quantitative; Survey of Hypogonadal men being treated with TRT recruited at a Urology clinic. Sample n = 79; Mean = 40 + 0.9.	USA	84.8% (n = 67) stated that they had no regret (NR) about their AAS use. 15.2% (n = 12) expressed regret (R) about their AAS use. The majority of the men were heterosexual and married. Men who regretted use were more likely to have no children (58.3%) while men who were not regretful of their prior AAS use were more likely to have 1–2 children (58.2%).	Patterns: NR Motivations: NR	40.5% (n = 32/79) of men with prior AAS use indicated having erectile dysfunction. A similar number of people in those men with R (50%, n = 6/12) and those with NR (38.8%, n = 26/67) experienced erectile dysfunction (P = 0.537, Figure 1(c)). Mood was similarly affected (R = 41.7%, n = 5/12; NR = 32.8%, n = 22/67). The men with regret, 25% (n = 3/12) did not understand the possible future impact of AAS use on their serum testosterone levels.	The findings in the current study are important when dealing with hypogonadal patients with ASIH seeking TST. It is valuable for men with ASIH to understand the impact that exogenous AAS may have had on their fertility.
Lenehan et al. (1996). A study of anabolic steroid use in the North-West of England. Journal Article. Mixed methods. Prevalence Survey & Interviews with gym users. Survey Sample n = 258; Age-range = 14–73. Interviews n = 379; Age-range = 17–56; Age of first use = 15–49.	England	AAS prevalence was higher in what were considered ‘hardcore’ gyms than ‘mixed’ gyms, with bodybuilders the largest user group. 58% were competitive bodybuilders. Increased muscle mass, strength, performance, recovery from injury, sex-drive and confidence most reported positive effects. Adverse effects reported included kidney problems, acne, water retention, infections and decreased sex drive. On cessation of AAS use over 1/3 of participants reported depression and suicidal ideation. Most commonly reported AAS used deca durabolin, testosterone, Dianabol, and Pronabol. 21.7% attended GP for AAS related issue. 2.1% were refused treatment by a GP because of their AAS use.	Patterns: NR Motivations: NR	NR	More AAS users in the 40–44-year age category than the 15–19 years. 35 were in the 40–74 age group.
Llamas-Velasco et al. (2021). Bilateral Nipple Enlargement as a Secondary Effect of Anabolic Drugs: A Histopathological Mimicker of Smooth Muscle Hamartoma. Clinical Case report. Sample n = 1; Age = 40	Spain	A 40-year-old male presented with progressive bilateral enlargement of both nipples excised due to cosmetic concerns. Disclosed AAS use.	Patterns: History of AAS use but details not specified. Motivations: To improve his physical performance	Bilateral enlargement of both nipples. symmetrical, cylindrical, well-defined and slightly indurated nipples of 10 mm diameter and 11 mm height attributed to AAS use.	Enlarged nipples excised with the clinical diagnosis of bilateral leiomyomas. Dermatopathologists and physicians should consider the side-effects of AAS use particularly lesions that present due to cosmetic concerns.
Long et al. (2019). Gerstmann syndrome complicating polycythemia secondary to anabolic steroid use. Clinical Case Report. Sample n = 1; Age = 49. Age of first use = in his teens.	USA	A 49-year-old man with presented with aphasia, ataxia, and right-sided weakness. Previous medical history was significant for a reported stroke in his 20s, panic attacks and rhabdomyolysis. Disclosed AAS use.	Patterns: A history of AAS use since his teens Still using AAS intermittently. He works as a personal trainer and trains 5–6 days/week (2–3 hours/day). Motivations: Competitive Bodybuilding.	Diagnosed with an AAS induced stroke.	The patient’s stroke symptoms improved after 2 days but he developed dysgraphia, dyscalculia, finger agnosia and left–right disorientation consistent with Gerstmann syndrome. Dysgraphia and left–right disorientation resolved but dyscalculia and finger agnosia remained on discharge.
Lovelock et al. (2021). A Case of Brachial Artery Infected Aneurysm Secondary to Infective Endocarditis from Intramuscular Steroid Use. Clinical Case Report. Sample n = 1; Age = 52.	Australia	52-year-old male presented with a 24-hour history of lethargy, blurred vision, and ataxia. This followed undiagnosed fevers and headaches with neck pain for 4 weeks. He had also developed left arm swelling and pain 2 days prior.	Patterns: AAS Use for the past 5 years Motivations: NR	A diagnosis of infective endocarditis of the mitral valve was made, secondary to C. hominis, likely due to intramuscular anabolic steroid use	The patient underwent excision and debridement of the infected aneurysm. Histopathology was consistent with infected thromboembolism with aneurysmal degeneration of the artery. The patient underwent mitral valve replacement 10 days later.
McVeigh and Begley (2017). Anabolic steroids in the UK: an increasing issue for public health. Review. Review using the two time points between 1995 (prior to legislation changes in the United Kingdom) and 2015, a review of the evidence related to health harms was conducted, in conjunction with needle and syringe programme (NSP) data in Cheshire & Merseyside (UK) relating to anabolic steroid users.	UK	Dramatic increase in the number of AAS users accessing NSPs, from 553 in 1995 to 2446 in 2015. Increased mean age of steroid using clients from 26 years old (median age of 25) in 1995 compared to 31 years old (median age of 30) in 2015. The percentage of steroid users has risen from 17.1% to 54.9% over the last 20 years.	Patterns: NR Motivations: NR	NR	Increased mean age of steroid using clients from 26 years old (median age of 25) in 1995 compared to 31 years old (median age of 30) in 2015. There is a need for widespread interventions in the context of increasing numbers of those injecting AAS. Greater engagement is required at gyms and other areas where AAS use is prevalent. Future research to estimate the prevalence of AAS use, drivers for AAS use, risk behaviours, and harm reduction initiatives require further research. The impact of the illicit market, the internet, and the demand for AAS also requires further research.
Patil et al. (2007). Near-fatal spontaneous hepatic rupture associated with anabolic androgenic steroid use: a case report. Clinical Case Report. Sample n = 1; Age = 43.	Wales	A 43-year-old man was brought to the accident and emergency department after he collapsed at home. He had epigastric pain for 2 days before the collapse. There was no history of trauma. Disclosed AAS use.	Patterns: He had stopped taking steroids 4 years previously. He had been taking AAS for 25 years, which included nandrolone decanoate, stanozolol, primabolin and most forms of testosterone. By comparison with the doses taken in the bodybuilding fraternity, his consumption was at the low end of the range of steroid usage. Motivations: NR	Spontaneous hepatic rupture which was attributed to history of AAS use.	Clinicians need to be aware of such a possibility for AAS use and related effects in a fit and healthy young person.
Pope et al. (2021). Anabolic-Androgenic Steroids, Violence, and Crime: Two Cases and Literature Review. Forensic Case Report. Forensic evaluations men who committed serious crimes while using AAS. Sample n = 2; Age = 58 and 50.	USA	Forensic case report account of 2 men who committed serious crimes while using AAS (only one used AAS older than 40 so will report on him only). The report highlighted that high doses of AAS can cause a minority of individuals to develop substantial personality and mood changes, and to display aggressiveness, violence, or criminal behaviour that appears entirely different from their usual personalities.	Patterns: NR Motivations: For performance enhancement initially. Then to maintain a physique to succeed in the club scene. Then at age 56 he used to bulk up for his job as a doorman.	NR	Significant need for criminologist in forensic or clinical settings to establish if the person who committed violent crimes was using AAS exactly at the time of the incident.
Rashid (2000). Testosterone abuse and affective disorders. Clinical Case Report. Sample n = 1; Age = 40.	USA	Case report of a man who presented to his psychiatrist and was using AAS to negate symptoms of perceived low testosterone. The patient described felling low, decreased energy, and decreased libido two months following cessation of AAS however in conjunction with his psychiatrist, he remained abstinent from AAS. Disclosed AAS use.	Patterns: Using AAS for the past 2 years. Motivations: To improve his self-image and help him develop muscualr physique, which made him happy, energetic, and outgoing.	NR	The report highlights the importance of specific treatment interventions for those wishing to cease AAS use
Ravindran et al. (2020). Myositis, rhabdomyolysis and severe hypercalcaemia in a body builder. Clinical Case Report. Sample n = 1; Age = 53.	Wales	A 53-year-old retired fire-fighter presented with severe constipation of many weeks’ duration. Disclosed AAS use.	Patterns: For bodybuilding Motivations: Use of growth hormone (GH) 2 IU/day and testosterone (T) 350 mg/day on a ‘6-weeks on and 4-weeks off’ regime for over 20 years	Severe symptomatic hypercalcaemia complicating acute inflammatory myositis and rhabdomyolysis. He also had AKI (with chronic kidney disease) and significant proteinuria due to Focal Segmental Glomerulosclerosis. He continued taking growth hormone and testosterone despite counselling but died suddenly of a myocardial infarction.	Diagnosis of hypercalcaemia may require multidisciplinary expertise and multiple and invasive investigations. There may be several disparate causes for hypercalcaemia, although one usually predominates. Maintaining ‘body image’ even with the use of harmful drugs may be an overpowering emotion despite counselling about their dangers.
Rosenfeld et al. (2011). Cholestatic jaundice, acute kidney injury and acute pancreatitis secondary to the recreational use of methandrostenolone: A case report. Clinical Case Report. Sample n = 1; Age = 50.	Canada	A 50-year-old man of Indian descent who presented with a six-week history of diffuse abdominal pain, anorexia and weight loss following an eight-week cycle of methandrostenolone use. Disclosed AAS use.	Patterns: NR Motivations: NR	Imaging was consistent with acute pancreatitis while a liver biopsy was consistent with intra-hepatic cholestasis and a kidney biopsy revealed evidence of acute tubular necrosis attributed to AAS use.	This was reported as the first known case of a patient developing pancreatitis as a result of anabolic androgenic steroid use.
Rothman et al. (2011). Anabolic androgenic steroid induced myocardial toxicity: An evolving problem in an ageing population. Clinical Case Report. Sample n = 1; Age = 62; Age of first use = 61	USA	62-year-old man presented with exertional dyspnoea culminating in marked exercise intolerance. Disclosed AAS use.	Patterns: Began regularly exercising at the age of 50 years. His exercise duration and intensity gradually increased over a several year period ultimately reaching 5 day per week regimen (2h of dedicated weightlifting and 30min of cardiovascular training). He began injecting AAS 1 year prior to admission. Reported the use of nandrolone 400–800 mg/week and methandrostenolone 20–40 mg/week to increase muscle mass and strength. Motivations: To increase lean muscle mass and strength.	Diagnosis of LV systolic dysfunction was made. The presumed aetiology was myocardial toxicity secondary to AAS exposure.	Cessation of anabolic steroids coupled with heart failure pharmacotherapy led to complete normalisation of LV size and function and a simultaneous increase in exercise tolerance. Several years after stopping AAS use he continues to train at a high level without limitations.
Shiber (2013). Pyomyositis Due To Anabolic Steroid Injection. Clinical Case Report. Sample n = 1; Age = 45.	USA	45-year-old amateur bodybuilder with pain and swelling at injection site for 3 days.	Patterns: NR Motivations: Bodybuilding	Pain and swelling at injection site for 3 days.	Treated with intravenous vancomycin and piperacillin-tazobactam. The wound was surgically debrided and he recovered and was discharged in 5 days.
Shinya et al. (2013). Caution for Anabolic Androgenic Steroid Use: A Case Report of Multiple Organ Dysfunction Syndrome. Clinical Case Report. Sample n = 1; Age = 42.	USA	42-year-old male amateur body builder developed multiple organ dysfunction syndrome and Acute respiratory distress syndrome. Disclosed AAS use.	Patterns: Injecting AAS: testosterone acetate, testosterone cypionate, testosterone decanoate, testosterone propionate, testosterone phenylpropionate, testosterone enanthate, and testosterone isocaproate, for a few years. Motivations: For muscle building	Nausea, vomiting, diarrhoea, and 5 days of shortness of breath and productive cough. He was hypoxic and had episodes of supraventricular tachycardia and rapid atrial flutter (ventricular rate 160–200 beats/min).	The relationship between AAS use and multi-organ dysfunction is not completely clear in this patient, but authors attributed his long history of AAS use with the systemic inflammatory response and multiple-organ dysfunction.
Tashiro et al. (2021). Subacute Stent Thrombosis After Primary Percutaneous Coronary Intervention in a Middle-Aged Anabolic Steroid–Abusing Bodybuilder. Clinical Case Report. Sample n = 1; Age = 54	Japan	A 54-year-old male bodybuilder who was abusing anabolic steroids developed an acute ST-segment elevation myocardial infarction after strenuous strength training. Disclosed AAS use.	Patterns: Oral oxandrolone (20 mg) and methandienone (40 mg) daily. He was training for a world-class bodybuilding competition and had been taking the AAS cyclically with 3 months “on” and 1 month “off” in addition to protein supplements for the last 3 years Motivations: Competitive bodybuilding.	Exercise-related acute MI followed by subacute thrombosis, potentially predisposed by abuse of AA.	The patient was referred to a comprehensive cardiac rehabilitation program in the rehabilitation hospital for secondary prevention and advised to discontinue use of AAS and vigorous exercise training.
Weinreb et al. (2010). Factitial soft tissue pseudotumor due to injection of anabolic steroids: a report of 3 cases in 2 patients. Clinical Case Report. Sample n = 1; Age = 49.	Canada	49-year-old man presented with a large left lateral thigh mass at injection site.	Patterns: Injecting AAS. Motivations: NR	Large left lateral thigh mass at injection site.	A benign reactive proliferation was diagnosed, and no treatment was needed.
Zahnow et al. (2018). Identifying a typology of men who use Anabolic Androgenic Steroids (AAS). Journal Article. Quantitative. Retrospective Data Analysis of AAS users from the Global Drug Survey 2015. Sample n = 611; Age-range = 16–68; Mean = 30.5; Age of first use = 24.39 ± 6.54	UK	Study developed a quantitative typology of AAS users. Four types: YOLO, Wellbeing, Expert and Athlete types. YOLO type are young, inexperienced, with high levels of risk; Wellbeing frequent the gym, concerns with image and wellbeing, less risky; Athlete type were more likely to be older, use of AAS and other IPEDs; Expert type minimal AAS and IPED use, low alcohol consumption, low risk.	Patterns: NR Motivations: Individuals in cluster 3 are motivated to use AAS to gain muscle and lose fat.	NR	Athlete types were more likely to be older. The Athlete type are noted for combining steroids with other enhancement drugs. While all clusters were motivated by muscle gain and fat loss to some degree, a far higher proportion of cluster three were motivated by these goals than other clusters which aligns with the goals of the competitive bodybuilder. individuals in cluster 3 tended to use a greater number of AAS and IPEDs.
Zahnow et al. (2017). Adverse effects, health service engagement, and service satisfaction among anabolic androgenic steroid users. Journal Article. Quantitative. Retrospective Data Analysis of AAS users from the Global Drug Survey 2015. Sample n = 253 men, 59 women; Age-range = 17–72; Mean = 29.8.	Global	35% reported seeking advice from GP due to AAS related adverse effects with the majority reluctant to do so. Sexual function issues were a driver for men to seek GP treatment. Those AAS user that did seek GP and medical advice were in the older cohort	Patterns: NR Motivations: NR	NR	On average, AAS users who engaged with health services were significantly older than those who did not

^aNR: Not reported. ^bNSP: Needle and Syringe Programs.

Table 4. Themes and categories emerging during thematic analysis.

Theme	Subtheme	Categories
Theme One
Characteristics of AAS Use	Age of Initiation	1. First use of AAS at aged 40 years or older documented in 8 records.
		2. Oldest age of initiation to use was aged 69 years.
		3. Evidence of increased age of initiation to use within UK national IPED studies over the past decade.
	Motivations for AAS Use	4. Motivations by AAS use documented in 23 records.
		5. Motivations by older males to initiate AAS use do not differ greatly from young males and included aesthetics, performance enhancement, and increasing musculature for bodybuilding.
		6. Wellbeing was considered a primary motivating factor for continued use and restarting use following a period of cessation.
		7. Wellbeing was associated with emotional happiness resulting from sexual function, feelings of youthfulness, male status, and the ability to perform sexually later in life.
	Sustained Harmful Patterns of Use	8. Dependence on AAS and attempts at cessation is documented in 5 records and may indicate the ‘neuroendocrine pathway’ for AAS dependence.
		9. Changes in patterns of use over time observed specifically in relation to continued use/not cycling and blasting and cruising.
		10. Prolonged cycles associated with psychological dependence and wellbeing.
		11. Some OMAAS do not perceive themselves as dependent, and that their AAS use is part of a healthy regime and a valued lifestyle.
Theme Two
Self-Reported Adverse Effects	Effect on Sexual Function and Fertility	12. Most reported adverse effects centred on erectile dysfunction, from AAS use testicular atrophy, and low libido.
		13. Psychological effects such as low mood and depressive symptoms.
		14. One study documented infertility and hypogonadal failure 30 months after cessation of AAS use.
	Other Self-Reported Adverse Effects	15. Other harms included hormonal imbalances, fatigue, breathlessness and dyspnoea, and injecting harms.
Theme Three
Health Harms Diagnosed by Medical	Cardiovascular Harms	16. Cardiovascular harms were reported in 14 studies.
Professional		17. Cardiovascular harms: left ventricular systolic dysfunction, left ventricular hypertrophy, right coronary artery infarct, decreased right ventricular function, dyslipidaemia, myocardial infarction, Class IV heart failure, myocardial dysfunction, coronary atherosclerosis, hypertension, elevated hs-CRP, hyperlipidaemia, increased haematocrit level, and refractory supraventricular tachycardia (see Table 5).
		18. Atherosclerotic disease was significantly linked to lifetime use of AAS.
		19. Cardiovascular harms (left ventricular hypertrophy, dyslipidaemia, coronary atherosclerosis, hypertension) diagnosed in OMAAS are those more often diagnosed in sedentary or obese populations.
	Hepatotoxicity	20. Liver injury from AAS use was reported in five clinical case reports.
		21. Reversal of liver injury on cessation of AAS use.
	Other Diagnosed Health Issues	22. Other diagnosed health harms were acute kidney injury, renal infarction, acute respiratory distress syndrome, type 2 Diabetes Mellitus, cholesterol imbalance, hypercalcaemia, inflammatory myositis, rhabdomyolysis, and erythrocytosis.
	Experiences of Healthcare	23. Only 3 studies documented experiences of healthcare by OMAAS.
		24. OMAAS were reluctant to engage with medical professionals.
		25. OMAAS with a longer lifetime of use than their younger counterparts wished to seek treatment for cessation of use.
		26. The treatment needs of an OMAAS will require a multi-disciplinary approach including physicians, endocrinologists, psychologists and psychiatrists, and addiction specialist practitioners.

Table 5. Cardiovascular harms terminology.

Cardiomyopathy	Chronic disease of the heart muscle.
Class IV Heart Failure	Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.
Coronary Atherosclerosis	Condition where arteries become clogged with fatty substances called plaques, or atheroma. These plaques cause the arteries to harden and narrow, restricting the blood flow and oxygen supply to vital organs, and increasing the risk of blood clots that could potentially block the flow of blood to the heart or brain.
Decreased Right Ventricular Function	Symptoms of right heart failure due to systemic venous congestion and/or low cardiac output. This includes exertional dyspnoea, fatigue, dizziness, ankle swelling, epigastric fullness and right upper abdominal discomfort or pain.
Dyslipidaemia	Dyslipidemia is the imbalance of lipids such as cholesterol, low-density lipoprotein cholesterol, (LDL-C), triglycerides, and high-density lipoprotein (HDL).
Elevated Hs-CRP	High-sensitivity C-reactive protein is produced by the body when blood-vessel walls are inflamed. The higher your levels of hs-CRP inked to an increased risk of heart attacks.
Erythrocytosis	A high concentration of red blood cells in the blood making the blood thicker and less able to travel through blood vessels and organs.
Hyperhomocysteinaemia	A trigger for many cardiovascular diseases, such as atherosclerosis and congestive heart failure.
Hypercalcaemia	When the calcium level in your blood is above normal. Too much calcium in your blood can weaken your bones, create kidney stones, and interfere with how your heart and brain work
Hyperlipidaemia	abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides.
Hypertension	High or raised blood pressure, a condition in which the blood vessels have persistently raised pressure.
Increased Haematocrit Levels	Hematocrit is the percentage of red blood cells in a person’s blood. High red blood cell levels could signal polycythemia, which can increase a person’s chance of developing a blood clot.
Inflammatory myositis	Inflammation of muscle
Infective Endocarditis	An infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve or a blood vessel.
Left Ventricular Hypertrophy	A thickening of the wall of the heart’s main pumping chamber. Eventually, the heart may fail to pump with as much force as needed.
Left Ventricular Systolic Dysfunction	A complication of myocardial infarction (MI) that leads to greatly increased risks of sudden death and of heart failure
Myocardial Dysfunction	The development of low cardiac output or ventricular systolic or diastolic dysfunction after cardiac arrest.
Myocardial Infarction	A heart attack - which happens when one or more areas of the heart muscle don’t get enough oxygen.
Rhabdomyolysis	The breakdown of muscle tissue that leads to the release of muscle fibre contents into the blood. These substances are harmful to the kidney and often cause kidney damage.
Refractory Supraventricular Tachycardia	An episode of SVT (irregularly fast heartbeat) that did not convert to sinus rhythm despite the administration of 2 doses of adenosine at or above the AHA-recommended doses.
Right Coronary Artery Infarct	A myocardial infarction (MI)

Figure 1. Flow chart of search strategy.

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