ECG Case 098

23 yr old male bodybuilder presented following a 30 minute episode of non-exertional chest pain. This ECG was taken when he was pain-free.

ECG Case 098 LITFL Top 100 EKG

Describe and interpret this ECG



  • 84 bpm


  • Regular
  • Sinus rhythm


  • Normal


  • PR – Normal (~120ms)
  • QRS – Normal (100ms)


  • Voltage criteria Left ventricular hypertrophy (LVH)
    • R V2 + S V4 = 45mm
  • LV ‘strain’ pattern
    • ST depression leads I, III, aVF, V3-6
    • T wave inversion leads I, III, aVF, V3-6
  • No features of left atrial abnormality


  • ECG features of LVH with secondary ST/T wave changes
  • Needs serial ECG’s to monitor for dynamic ST or T wave changes

Note the patient is a young male and whilst voltage criteria for LVH can be seen in the athletic heart it should NOT be associated with left axis deviation, left atrial abnormality, pathological Q waves or ST / T wave changes – these are abnormal and require further investigation


On further history the patient admitted to prior anabolic steroid use, although he denied recent use. He had recently, within the last few days, started taking clenbuterol ( a potent sympathomimetic amine) to help with weight loss (aka ‘cutting’) prior to a competition.

Clenbuterol can be used to treat asthma in veterinary medicine but it is not approved for human use in Australia, US or UK and is banned for use by Olympic athletes. It potential side effects are those of sympathomimetic toxicity including tachycardia, hypertension, hyperthermia and seizure.

The patients initial troponin was 1.08 (ug/L cTnI) and he was admitted for investigation under the cardiology team. He underwent an angiogram which was normal and an echo which showed only mild concentric hypertrophy. The likely cause of his presentation and myocardial injury was attributed to vasospasm / demand ischaemia secondary to clenbuterol.

Other bodybuilding drugs and complications

Use of supplements and medications is not uncommon among bodybuilders and must be explored on clinical history. Specific complications must be considered including:

Anabolic Steroid Related

  • Sexual –  Hypogonadism / testicular atrophy, Impaired spermatogenesis
  • Skin – Baldness, Acne, Gynaecomastia
  • Psychiatric disturbance
  • Hepatic toxicity
  • Carcinogenesis
  • Cardiac –  Hypertrophy, Myocardial fibrosis, Dyslipidemia, Hypertension, Arrhythmia, Myocardial infarction, Sudden Cardiac Death

Supplement Related

  • Hepatic toxicity
  • Renal toxicity
  • Dyslipidaemia
  • Contamination of supplements

Other agents of abuse

  • Insulin
  • Diuretics
  • HGH
  • Testosterone
  • Anti-estrogens
  • Synthol – oil injested into muscle – risks related to local effects including necrosis, fibrosis, infection

TOP 100 ECG Series

Emergency Medicine Specialist MBChB FRCEM FACEM. Medical Education, Cardiology and Web Based Resources | @jjlarkin78 | LinkedIn |

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