madman
Super Moderator
Abstract:
Background and objectives: Anabolic-androgenic steroids (AASs) are a group of synthetic molecules derived from testosterone and its related precursors. AASs are widely used illicitly by adolescents and athletes, especially by bodybuilders, both for aesthetic uses and as performance enhancers to increase muscle growth and lean body mass. When used illicitly they can damage health and cause disorders affecting several functions. Sudden cardiac death (SCD) is the most common medical cause of death in athletes. SCD in athletes has also been associated with the use of performance-enhancing drugs. This review aimed to focus on deaths related to AAS abuse to investigate the cardiac pathophysiological mechanism that underlies this type of death, which still needs to be fully investigated.
Materials and Methods: This review was conducted using PubMed Central and Google Scholar databases, until 21 July 2020, using the following key terms: “((Sudden cardiac death) OR (Sudden death)) AND ((androgenic anabolic steroid) OR (androgenic anabolic steroids) OR (anabolic-androgenic steroids) OR (anabolic-androgenic steroid))”. Thirteen articles met the inclusion and exclusion criteria, for a total of 33 reported cases.
Results: Of the 33 cases, 31 (93.9%) were males while only 2 (61%) were females. The mean age was 29.79 and, among sportsmen, the most represented sports activity was bodybuilding. In all cases there was a history of AAS abuse or a physical phenotype suggesting AAS use; the total usage period was unspecified in most cases. In 24 cases the results of the toxicological analysis were reported. The most detected AASs were nandrolone, testosterone, and stanozolol. The most frequently reported macroscopic alterations were cardiomegaly and left ventricular hypertrophy, while the histological alterations were foci of fibrosis and necrosis of the myocardial tissue.
Conclusions: Four principal mechanisms responsible for SCD have been proposed in AAS abusers: the atherogenic model, the thrombosis model, the model of vasospasm induced by the release of nitric oxide, and the direct myocardial injury model. Hypertrophy, fibrosis, and necrosis represent a substrate for arrhythmias, especially when combined with exercise. Indeed, AAS use has been shown to change physiological cardiac remodeling of athletes to pathophysiological cardiac hypertrophy with an increased risk of life-threatening arrhythmias.
1. Introduction
AASs are a group of synthetic molecules derived from testosterone and its related precursors. AAS was developed to minimize the androgenic effects of testosterone and maximize the anabolic effects promoting the growth of skeletal muscles [1–3]. AASs can be administered orally, by intramuscular or subcutaneous injection, by pellet subcutaneous implantation, or by application on the skin.
Only a few AAS are used or proposed for therapeutic use, mainly in replacement treatment of hypogonadism [4,5]. Direct testosterone replacement therapy (TRT) is the only FDA-approved therapy for the treatment of male hypogonadism [6]. Oxandrolone, instead, is used to fight the protein catabolism associated with long-term use of corticosteroids and in the treatment of bone pain due to osteoporosis [7]. Clinical studies have demonstrated the efficacy of oxandrolone in the treatment of acute catabolic disorders, such as severe burns or severe trauma, and chronic catabolic disorders such as AIDS-associated cachexia or neuromuscular diseases such as Duchenne muscular dystrophy [8]. As well as for therapeutic use, AAS are widely used illicitly by adolescents and athletes, especially by bodybuilders, both for aesthetic uses and as performance enhancers to increase muscle growth and lean body mass, in consideration of their significant anabolic effect [9,10].
Although the use of AASs is now widespread around the world, with around ten million users, there are some geographical differences. The Middle East has the highest prevalence rate, with 21.7% of world users, followed by South America (4.8%), Europe (3.8%), North America (3.0%), Oceania (2.6%), Africa (2.4%), and Asia (0.2%). Among developed countries, the highest prevalence is found in Scandinavia, the United States, and countries of the British Commonwealth. The highest overall prevalence rate of AAS use was found in recreational sportspeople (18.4%), followed by athletes (13.4%), prisoners (12.4%), and drug users (8.0%). Non-athletes have the lowest prevalence rate that is estimated to be about 1% [11,12]. The global lifetime prevalence rate of AAS use is estimated to be 3.3%, greater in men than women (6.4% vs. 1.6%). As concerns the age of AAS users, teenagers have a higher overall prevalence rate (2.5%) than people older than 19 years (1.9%). The prevalence rate among high-school students was 2.3% [11,13,14].
While the use of AASs for medical indications is relatively safe, when used illicitly they can damage health and cause disorders affecting several functions (cardiovascular, reproductive, musculoskeletal, endocrine, renal, immunologic, and neuropsychiatric) [3,15–23]. These side effects include cardiac injuries such as fibrosis, cardiac hypertrophy, and dilated cardiomyopathy with an increased risk for myocardial infarction, arrhythmias, and sudden cardiac death [3,24–27]
AAS are typically used in phases referred to as “cycles”. To reduce the dangerous consequences of continuous AAS use at supraphysiological doses, abusers often introduce changes to their intake [28,29]. “Stacking” consumption can also involve nutritional supplements, complements, or other substances [30–32]. The substances most frequently are taken at the same time as AASs are alcohol, amphetamines, aspirin, cannabinoids, caffeine, clomiphene citrate, cocaine, codeine, creatine, ephedrine, erythropoietin, furosemide, gamma-hydroxybutyrate (GHB), growth hormone, heroin, insulin, insulin-like growth 1 (IGF-1), melanotan, protein powder, tamoxifen, thyroxine, and tobacco. [33]
Sudden cardiac death (SCD) is generally defined as sudden unexpected death or arrest from a presumed cardiac cause, which occurs within one hour of symptom onset if witnessed, otherwise within 24 h, in a person without any prior condition that would appear fatal [34–36].
This review aims to investigate the relationship between the use of anabolic-androgenic steroids (AAS) and sudden cardiac death in athletes and identify the possible etiological mechanism.
4. Discussion
Data emerging from our study confirm the higher prevalence of ASS assumption among young males (93.9% males compared to 6.1%females, mean age 29.79 years), especially if they are bodybuilders (39%). In none of the cases in which anamnestic data were present was there a personal history of the disease or a family history of heart disease before age 50. In the 33 cases examined, the most frequently reported macroscopic changes were cardiomegaly (33%) and left ventricular hypertrophy (30%). The most frequently reported histological changes were foci of fibrosis (79%) and necrosis (52%) of myocardial tissue. In all cases, autopsies ruled out causes of extracardiac death, and SCD was correlated with AAS use. Sudden cardiac death (SCD) is generally defined as sudden unexpected death or arrest from a presumed cardiac cause, which occurs within one hour of symptom onset if witnessed, otherwise within 24 h, in a person without any prior condition that would appear fatal [34–36]. SCD in athletes is an event that profoundly impacts society because athletes are generally seen as a healthy category of people. Although SCD is the most common medical cause of death in athletes, its true incidence is unknown. The risk of SCD in athletes is 2 to 3 times greater than that in the general population. This difference may be due to typical athletes' demographic factors, such as sex, age, and ethnicity. Potential mechanisms for SCD consist of inflammation, mechanical factors such as ventricular hypertrophy or fibrosis, neurological and metabolic comorbidities, and hereditary factors, arrhythmic mechanisms of abnormal ventricular repolarization, conduction, or autonomic innervation [49]. The etiology of SCD in younger athletes (<35 years of age) is mainly related to inherited cardiac conditions, instead, in older athletes, it is related to atherosclerotic coronary artery disease (CAD) [50–53]. Left ventricular hypertrophy (LVH) has been recognized as an independent risk factor for sudden cardiac death. The high mortality and sudden cardiac death associated with LVH is related to ventricular arrhythmia. Indeed, hypertrophied myocardium has a typical pro-arrhythmic electrophysiological phenotype and predisposes to the presence of myocardial ischemia. The main abnormality is a prolongation of the action potential duration and refractoriness, which represents the substrate for arrhythmias [54]. Increased risk of ventricular arrhythmias and SCD, associated with hypertrophy, are related to complex processes involving myocardial cells, interstitium, coronary flow reserve, and neurohumoral activation [55]. SCD in athletes has also been associated with the use of performance-enhancing drugs, both anabolic-androgenic steroids and nonsteroidal agents [56]. AAS users often combine the assumption of anabolic substances with other substances such as cocaine, methamphetamine, and smart drugs. These data are in agreement with the results of our review. Mixing two or more substances increases the risk of negative drug interactions, worsening any adverse effects, including SCD [17].
The higher prevalence of AAS use among athletes, especially non-professionals, can be explained by their determination to achieve a perfect body and to improve performance and self-esteem. Indeed, the positive effects of AAS use are the increase of muscle mass, strength, energy and concentration, and the reduction of fat mass [57,58]. However, the use of anabolic-androgenic steroids has also many negative effects. Many of these are mild and transient (fluid retention, acne, agitation, gynecomastia, aggressiveness), but others are more serious and can damage multiple organs and functions, such as cardiovascular, reproductive, musculoskeletal, endocrine, renal, immunologic, and neuropsychiatric functions [2,57–60]. The cardiovascular system is one of the most affected by the side effects of AAS use. AAS use enhances vascular resistance and blood pressure, pro-inflammatory biomarker profile, and sympathetic tone alters serum lipoproteins and produces direct myocardial toxicity [53,61]. The adverse cardiovascular events reported are: impaired left ventricular function, arterial thrombosis, pulmonary embolism, and left ventricular hypertrophy, associated with myocytolysis and fibrosis [1]. It is reported that AAS abuse can promote cardiac tissue growth, leading to hypertrophic cardiomyopathy, followed by apoptotic cell death. This phenomenon is associated with ventricular remodeling, cardiomyopathy, myocardial infarction, and SCD and can explain how AAS may lead to cardiac death without coronary thrombosis or atherosclerosis [62,63]. AASs cause cardiac hypertrophy by a direct action on cardiac androgen receptors and these effects are directly proportional to the dose, time, and duration of administration [45]. Melchert and Welder proposed at least four hypothetical models explaining how AASs cause cardiovascular side effects. The atherogenic model concerns the alterations on lipoprotein serum levels caused by AASs, increasing the risk of atherosclerosis. The thrombosis model regards enhancing platelet aggregation and polycythemia that increase the risk of thrombus formation. The third model involves vasospasm caused by nitric oxide release induced by anabolic agents. The direct myocardial injury model concerns direct myocardial toxicity causing apoptosis, with increased collagen deposition, fibrosis, and altered microcirculation resulting in chronic ischemic damage. All of these mechanisms associate AAS use with a high risk of SCD [64,65].
5. Conclusions
Because of the high prevalence of AAS use among athletes, toxicological investigations are therefore fundamental in those cases of sudden death in which there is suspicion of AAS consumption. The cardiovascular system is one of the most affected by the side effects of AAS use. AAS use enhances vascular resistance and increases blood pressure, pro-inflammatory biomarker profile, sympathetic tone, alters serum lipoproteins and produces direct myocardial toxicity. In agreement with the evidence in the literature, the most reported macroscopic heart changes reported in our review were cardiomegaly and hypertrophy, and the main histological changes were necrosis of myocardial tissue and foci of fibrosis. Hypertrophy, fibrosis, and necrosis represent a substrate for arrhythmias, especially when combined with exercise. AAS use has been shown to change physiological cardiac remodeling of athletes to pathophysiological cardiac hypertrophy with an increased risk of life-threatening arrhythmias. The evaluation of the parameters of electrocardiographic repolarization at rest and post-exercise, using SAECG, could provide diagnostic and prognostic information on the risk of cardiac arrhythmias and SCD in apparently healthy subjects who chronically use supraphysiological doses of AAS [27,81].
Since the pathophysiological mechanisms that lead to SCD in subjects who use AAS have not yet been fully clarified, the link between AAS abuse and SCD is probably underestimated, considering the few data in the literature.
Toxicological investigations, performed on different matrices, such as blood, urine, and hair, can confirm the use of AAS or other drugs that may have played a role in the death. A complete autopsy with histological and immunohistochemical studies, with particular regard to the organs in which anabolic adverse events occur most frequently, is mandatory to evaluate the relationship between AAS use and SCD.
Given the young age of the subjects who usually use AASs and given the importance of the consequences related to their abuse, the identification of new tools to study AAS use, such as miRNAs, could be an important goal for the scientific community.
Nowadays, clinicians must pay attention to indicative signs of AAS use, considering those physical and epidemiological characteristics that can lead to the suspicion of abuse of these drugs to implement primary prevention measures of the serious adverse effects of AAS use. An interesting challenge would be to further investigate these findings to be able to use these biomarkers both to facilitate the post-mortem diagnosis of sudden deaths related to AAS abuse and as a screening method in living subjects to prevent fatal consequences.
Background and objectives: Anabolic-androgenic steroids (AASs) are a group of synthetic molecules derived from testosterone and its related precursors. AASs are widely used illicitly by adolescents and athletes, especially by bodybuilders, both for aesthetic uses and as performance enhancers to increase muscle growth and lean body mass. When used illicitly they can damage health and cause disorders affecting several functions. Sudden cardiac death (SCD) is the most common medical cause of death in athletes. SCD in athletes has also been associated with the use of performance-enhancing drugs. This review aimed to focus on deaths related to AAS abuse to investigate the cardiac pathophysiological mechanism that underlies this type of death, which still needs to be fully investigated.
Materials and Methods: This review was conducted using PubMed Central and Google Scholar databases, until 21 July 2020, using the following key terms: “((Sudden cardiac death) OR (Sudden death)) AND ((androgenic anabolic steroid) OR (androgenic anabolic steroids) OR (anabolic-androgenic steroids) OR (anabolic-androgenic steroid))”. Thirteen articles met the inclusion and exclusion criteria, for a total of 33 reported cases.
Results: Of the 33 cases, 31 (93.9%) were males while only 2 (61%) were females. The mean age was 29.79 and, among sportsmen, the most represented sports activity was bodybuilding. In all cases there was a history of AAS abuse or a physical phenotype suggesting AAS use; the total usage period was unspecified in most cases. In 24 cases the results of the toxicological analysis were reported. The most detected AASs were nandrolone, testosterone, and stanozolol. The most frequently reported macroscopic alterations were cardiomegaly and left ventricular hypertrophy, while the histological alterations were foci of fibrosis and necrosis of the myocardial tissue.
Conclusions: Four principal mechanisms responsible for SCD have been proposed in AAS abusers: the atherogenic model, the thrombosis model, the model of vasospasm induced by the release of nitric oxide, and the direct myocardial injury model. Hypertrophy, fibrosis, and necrosis represent a substrate for arrhythmias, especially when combined with exercise. Indeed, AAS use has been shown to change physiological cardiac remodeling of athletes to pathophysiological cardiac hypertrophy with an increased risk of life-threatening arrhythmias.
1. Introduction
AASs are a group of synthetic molecules derived from testosterone and its related precursors. AAS was developed to minimize the androgenic effects of testosterone and maximize the anabolic effects promoting the growth of skeletal muscles [1–3]. AASs can be administered orally, by intramuscular or subcutaneous injection, by pellet subcutaneous implantation, or by application on the skin.
Only a few AAS are used or proposed for therapeutic use, mainly in replacement treatment of hypogonadism [4,5]. Direct testosterone replacement therapy (TRT) is the only FDA-approved therapy for the treatment of male hypogonadism [6]. Oxandrolone, instead, is used to fight the protein catabolism associated with long-term use of corticosteroids and in the treatment of bone pain due to osteoporosis [7]. Clinical studies have demonstrated the efficacy of oxandrolone in the treatment of acute catabolic disorders, such as severe burns or severe trauma, and chronic catabolic disorders such as AIDS-associated cachexia or neuromuscular diseases such as Duchenne muscular dystrophy [8]. As well as for therapeutic use, AAS are widely used illicitly by adolescents and athletes, especially by bodybuilders, both for aesthetic uses and as performance enhancers to increase muscle growth and lean body mass, in consideration of their significant anabolic effect [9,10].
Although the use of AASs is now widespread around the world, with around ten million users, there are some geographical differences. The Middle East has the highest prevalence rate, with 21.7% of world users, followed by South America (4.8%), Europe (3.8%), North America (3.0%), Oceania (2.6%), Africa (2.4%), and Asia (0.2%). Among developed countries, the highest prevalence is found in Scandinavia, the United States, and countries of the British Commonwealth. The highest overall prevalence rate of AAS use was found in recreational sportspeople (18.4%), followed by athletes (13.4%), prisoners (12.4%), and drug users (8.0%). Non-athletes have the lowest prevalence rate that is estimated to be about 1% [11,12]. The global lifetime prevalence rate of AAS use is estimated to be 3.3%, greater in men than women (6.4% vs. 1.6%). As concerns the age of AAS users, teenagers have a higher overall prevalence rate (2.5%) than people older than 19 years (1.9%). The prevalence rate among high-school students was 2.3% [11,13,14].
While the use of AASs for medical indications is relatively safe, when used illicitly they can damage health and cause disorders affecting several functions (cardiovascular, reproductive, musculoskeletal, endocrine, renal, immunologic, and neuropsychiatric) [3,15–23]. These side effects include cardiac injuries such as fibrosis, cardiac hypertrophy, and dilated cardiomyopathy with an increased risk for myocardial infarction, arrhythmias, and sudden cardiac death [3,24–27]
AAS are typically used in phases referred to as “cycles”. To reduce the dangerous consequences of continuous AAS use at supraphysiological doses, abusers often introduce changes to their intake [28,29]. “Stacking” consumption can also involve nutritional supplements, complements, or other substances [30–32]. The substances most frequently are taken at the same time as AASs are alcohol, amphetamines, aspirin, cannabinoids, caffeine, clomiphene citrate, cocaine, codeine, creatine, ephedrine, erythropoietin, furosemide, gamma-hydroxybutyrate (GHB), growth hormone, heroin, insulin, insulin-like growth 1 (IGF-1), melanotan, protein powder, tamoxifen, thyroxine, and tobacco. [33]
Sudden cardiac death (SCD) is generally defined as sudden unexpected death or arrest from a presumed cardiac cause, which occurs within one hour of symptom onset if witnessed, otherwise within 24 h, in a person without any prior condition that would appear fatal [34–36].
This review aims to investigate the relationship between the use of anabolic-androgenic steroids (AAS) and sudden cardiac death in athletes and identify the possible etiological mechanism.
4. Discussion
Data emerging from our study confirm the higher prevalence of ASS assumption among young males (93.9% males compared to 6.1%females, mean age 29.79 years), especially if they are bodybuilders (39%). In none of the cases in which anamnestic data were present was there a personal history of the disease or a family history of heart disease before age 50. In the 33 cases examined, the most frequently reported macroscopic changes were cardiomegaly (33%) and left ventricular hypertrophy (30%). The most frequently reported histological changes were foci of fibrosis (79%) and necrosis (52%) of myocardial tissue. In all cases, autopsies ruled out causes of extracardiac death, and SCD was correlated with AAS use. Sudden cardiac death (SCD) is generally defined as sudden unexpected death or arrest from a presumed cardiac cause, which occurs within one hour of symptom onset if witnessed, otherwise within 24 h, in a person without any prior condition that would appear fatal [34–36]. SCD in athletes is an event that profoundly impacts society because athletes are generally seen as a healthy category of people. Although SCD is the most common medical cause of death in athletes, its true incidence is unknown. The risk of SCD in athletes is 2 to 3 times greater than that in the general population. This difference may be due to typical athletes' demographic factors, such as sex, age, and ethnicity. Potential mechanisms for SCD consist of inflammation, mechanical factors such as ventricular hypertrophy or fibrosis, neurological and metabolic comorbidities, and hereditary factors, arrhythmic mechanisms of abnormal ventricular repolarization, conduction, or autonomic innervation [49]. The etiology of SCD in younger athletes (<35 years of age) is mainly related to inherited cardiac conditions, instead, in older athletes, it is related to atherosclerotic coronary artery disease (CAD) [50–53]. Left ventricular hypertrophy (LVH) has been recognized as an independent risk factor for sudden cardiac death. The high mortality and sudden cardiac death associated with LVH is related to ventricular arrhythmia. Indeed, hypertrophied myocardium has a typical pro-arrhythmic electrophysiological phenotype and predisposes to the presence of myocardial ischemia. The main abnormality is a prolongation of the action potential duration and refractoriness, which represents the substrate for arrhythmias [54]. Increased risk of ventricular arrhythmias and SCD, associated with hypertrophy, are related to complex processes involving myocardial cells, interstitium, coronary flow reserve, and neurohumoral activation [55]. SCD in athletes has also been associated with the use of performance-enhancing drugs, both anabolic-androgenic steroids and nonsteroidal agents [56]. AAS users often combine the assumption of anabolic substances with other substances such as cocaine, methamphetamine, and smart drugs. These data are in agreement with the results of our review. Mixing two or more substances increases the risk of negative drug interactions, worsening any adverse effects, including SCD [17].
The higher prevalence of AAS use among athletes, especially non-professionals, can be explained by their determination to achieve a perfect body and to improve performance and self-esteem. Indeed, the positive effects of AAS use are the increase of muscle mass, strength, energy and concentration, and the reduction of fat mass [57,58]. However, the use of anabolic-androgenic steroids has also many negative effects. Many of these are mild and transient (fluid retention, acne, agitation, gynecomastia, aggressiveness), but others are more serious and can damage multiple organs and functions, such as cardiovascular, reproductive, musculoskeletal, endocrine, renal, immunologic, and neuropsychiatric functions [2,57–60]. The cardiovascular system is one of the most affected by the side effects of AAS use. AAS use enhances vascular resistance and blood pressure, pro-inflammatory biomarker profile, and sympathetic tone alters serum lipoproteins and produces direct myocardial toxicity [53,61]. The adverse cardiovascular events reported are: impaired left ventricular function, arterial thrombosis, pulmonary embolism, and left ventricular hypertrophy, associated with myocytolysis and fibrosis [1]. It is reported that AAS abuse can promote cardiac tissue growth, leading to hypertrophic cardiomyopathy, followed by apoptotic cell death. This phenomenon is associated with ventricular remodeling, cardiomyopathy, myocardial infarction, and SCD and can explain how AAS may lead to cardiac death without coronary thrombosis or atherosclerosis [62,63]. AASs cause cardiac hypertrophy by a direct action on cardiac androgen receptors and these effects are directly proportional to the dose, time, and duration of administration [45]. Melchert and Welder proposed at least four hypothetical models explaining how AASs cause cardiovascular side effects. The atherogenic model concerns the alterations on lipoprotein serum levels caused by AASs, increasing the risk of atherosclerosis. The thrombosis model regards enhancing platelet aggregation and polycythemia that increase the risk of thrombus formation. The third model involves vasospasm caused by nitric oxide release induced by anabolic agents. The direct myocardial injury model concerns direct myocardial toxicity causing apoptosis, with increased collagen deposition, fibrosis, and altered microcirculation resulting in chronic ischemic damage. All of these mechanisms associate AAS use with a high risk of SCD [64,65].
5. Conclusions
Because of the high prevalence of AAS use among athletes, toxicological investigations are therefore fundamental in those cases of sudden death in which there is suspicion of AAS consumption. The cardiovascular system is one of the most affected by the side effects of AAS use. AAS use enhances vascular resistance and increases blood pressure, pro-inflammatory biomarker profile, sympathetic tone, alters serum lipoproteins and produces direct myocardial toxicity. In agreement with the evidence in the literature, the most reported macroscopic heart changes reported in our review were cardiomegaly and hypertrophy, and the main histological changes were necrosis of myocardial tissue and foci of fibrosis. Hypertrophy, fibrosis, and necrosis represent a substrate for arrhythmias, especially when combined with exercise. AAS use has been shown to change physiological cardiac remodeling of athletes to pathophysiological cardiac hypertrophy with an increased risk of life-threatening arrhythmias. The evaluation of the parameters of electrocardiographic repolarization at rest and post-exercise, using SAECG, could provide diagnostic and prognostic information on the risk of cardiac arrhythmias and SCD in apparently healthy subjects who chronically use supraphysiological doses of AAS [27,81].
Since the pathophysiological mechanisms that lead to SCD in subjects who use AAS have not yet been fully clarified, the link between AAS abuse and SCD is probably underestimated, considering the few data in the literature.
Toxicological investigations, performed on different matrices, such as blood, urine, and hair, can confirm the use of AAS or other drugs that may have played a role in the death. A complete autopsy with histological and immunohistochemical studies, with particular regard to the organs in which anabolic adverse events occur most frequently, is mandatory to evaluate the relationship between AAS use and SCD.
Given the young age of the subjects who usually use AASs and given the importance of the consequences related to their abuse, the identification of new tools to study AAS use, such as miRNAs, could be an important goal for the scientific community.
Nowadays, clinicians must pay attention to indicative signs of AAS use, considering those physical and epidemiological characteristics that can lead to the suspicion of abuse of these drugs to implement primary prevention measures of the serious adverse effects of AAS use. An interesting challenge would be to further investigate these findings to be able to use these biomarkers both to facilitate the post-mortem diagnosis of sudden deaths related to AAS abuse and as a screening method in living subjects to prevent fatal consequences.
