Reply to Letter to the Editors

Dear Editors,

We greatly acknowledge the letter by colleagues Kindermann and Urhausen with remarks on our manuscript entitled “Prospective echocardiographic assessment of androgenic-anabolic steroid effects on cardiac structure and function in strength athletes” which was published in Int J Sports Med 2003; 24: 344 - 351. Kindermann and Urhausen provide four points that need clarification.

First, in their introduction they state that there are indications that androgenic-anabolic steroids (AAS) cause detrimental effects on the cardiac structure and function. Their statement is based on the studies of De Piccoli et al., Sachtleben et al. and Urhausen et al. [[1], [5], [6]]. Although we largely agree with their statement, in our opinion the basis for their statement is not adequate since they refer mainly to cross-sectional studies, i.e. the studies by De Piccoli et al. and Urhausen et al. [[1], [6]]. A cross-sectional study design does not provide evidence for a causal relationship between AAS administration and echocardiographic observations. At most they indicate an association. The longitudinal study used as basis for their statement, the study by Sachtleben et al. [[5]], has been subject to criticism and in our opinion their results have to be interpreted with caution [[3], [4]]. Nevertheless, based on other evidence we share the concerns of Kindermann and Urhausen that AAS may cause detrimental effects on the heart [[4]].

Second, Kindermann and Urhausen provide an interesting point with respect to measurement of the systolic and diastolic function. They propose that evaluation of diastolic function by measuring the transmitral blood flow profile by means of standard Doppler might be not sensitive enough to detect alterations. Based on their own observation the assessment of regional myocardial velocities by means of tissue Doppler velocity imaging seems to be more sensitive. Unfortunately, at the time we performed our study we did not have the opportunity to perform such measurements due to equipment limitations. Nowadays, as we know also from our own experiences, these measurements provide promising results.

The third point focuses on the baseline echocardiographic measurements of our study subjects. Kindermann and Urhausen questioned whether our statement that in all subjects cardiac enlargements were seen, was correct. We have to compliment Kindermann and Urhausen for reading the manuscript thoroughly since our statement is, indeed, incorrect. The phrase has to be corrected as follows: “In the minority of the subjects of both studies, the hearts showed enlargement of the left ventricle and left ventricular wall thickness”. We have to apologize for overlooking this error.

Finally, for determination of the left ventricular mass we used the generally accepted method of Devereux et al. [[2]].

F. Hartgens, E. C. Cheriex, H. Kuipers

References

• 1 De Piccoli B, Giada F, Benettin A, Saliori F, Piccolo E. Anabolic steroid use in body builders: an echocardiographic study of left ventricle morphology and function.  Int J Sports Med. 1991;  12 408-412
• 2 Devereux R B, Lutas E M, Casale P N, Kligfield P, Eisenberg R R, Hammond I W, Miller D H, Reis G, Alderman M H, Laragh J H. Standardization of M-mode echocardiographic left ventricular anatomic measurements.  J Am Coll Cardiol. 1984;  4 1222-1230
• 3 Hartgens F, Cheriex E G, Kuipers H. Prospective echocardiographic assessment of androgenic-anabolic steroids effects on cardiac structure and function in strength athletes.  Int J Sports Med. 2003;  24 344-351
• 4 Hartgens F, Kuipers H. The effects of androgenic-anabolic steroids in athletes a review. Accepted for publication in Sports Medicine 2004
• 5 Sachtleben T R, Berg K E, Elias B A, Cheatham J P, Felix G L, Hofschire P J. The effects of anabolic steroids on myocardial structure and cardiovascular fitness.  Med Sci Sports Exerc. 1993;  25 1240-1245
• 6 Urhausen A, Hölpes R, Kindermann W. One- and two-dimensional echocardiography in bodybuilders using anabolic steroids.  Eur J Appl Physiol. 1989;  58 633-640
• 7 Urhausen A, Krieg A, Scharhag J, Kindermann W. Tissue velocity imaging in the assessment of left ventricular function in endurance athletes vs. strength athletes abusing anabolic steroids.  Med Sci Sports Exerc. 2003;  35 318