Duration-Dependent Cardiac Effects of Anabolic-Androgenic Steroid Use in Strength-Trained Athletes: A Systematic Review and Meta-Analysis.

PURPOSE: Nonmedical anabolic-androgenic steroid (AAS) use is increasing, and its duration-dependent cardiac effects remain unclear. We evaluated cardiac structure and function in AAS-using strength-trained athletes, overall and by exposure duration. METHODS: We searched PubMed, Embase, Cochrane Central, and SCOPUS through November 2025 for observational studies comparing AAS-using and nonusing strength-trained athletes of either sex. Random-effects models pooled mean differences (MD) overall and across four exposure strata (<6 months, 6 months-3 years, 3-6 years, >6 years); meta-regression assessed duration as a continuous moderator. RESULTS: Forty studies (1906 athletes; 95% male) were included. Overall, AAS users showed reduced left ventricular ejection fraction (LVEF; 29 studies; MD -2.84%; 95% CI -4.24 to -1.44; p < 0.01), impaired global longitudinal strain (GLS; MD +3.27%; p < 0.01), and increased left ventricular mass index (LVMI; MD +18.21 g/m2; p < 0.01). Septal thickening was detectable before six months, preceding functional impairment. LVEF, LVMI, and posterior wall thickness (PWT) differed significantly across strata (all p ≤ 0.03), with the largest LVEF reduction beyond six years (MD -7.39%; 95% CI -10.71 to -4.07). Meta-regression suggested that exposure duration was associated with variation in selected structural and functional outcomes, corroborating LVEF, LVMI, and PWT, while GLS, E/e', and E/A ratio showed no significant association. Right ventricular strain was impaired in an exploratory, non-stratified analysis. CONCLUSION: AAS use is associated with cardiac structural and functional abnormalities, with exposure duration associated with selected, but not all, outcomes. These cross-sectional comparisons do not establish within-person progression; longitudinal surveillance with deformation imaging is warranted.