In a male adult using supraphysiologic trenbolone 150 mg weekly and testosterone 400 mg weekly who presents with new‑onset dyspnea, what is the probability that a comprehensive cardiopulmonary work‑up is warranted and what are the five most likely differential diagnoses?

Dyspnea in Supraphysiologic Anabolic Steroid Use: Workup and Differential Diagnosis

A comprehensive cardiopulmonary workup is mandatory in any male presenting with dyspnea while using trenbolone 150 mg weekly combined with testosterone 400 mg weekly, as these supraphysiologic doses create multiple life-threatening cardiopulmonary risks with high probability of serious pathology.

Probability of Requiring Full Workup

The probability approaches 100% that comprehensive evaluation is warranted, given:

• Both agents are at supraphysiologic doses far exceeding physiologic testosterone replacement (testosterone 400 mg weekly is nearly double the 600 mg/week threshold shown to cause adverse effects, and trenbolone has approximately 3-fold greater androgenic potency than testosterone) 1, 2

• Cardiovascular event rates are dramatically elevated with supraphysiologic testosterone, with one major trial showing 7% cardiovascular event rates versus 1% in placebo groups 3

• Multiple dose-dependent hematologic and cardiovascular complications occur at these doses, including polycythemia, thrombosis, myocardial infarction, and pulmonary embolism 3, 4

Top 5 Differential Diagnoses (Ranked by Mortality Risk)

1. Acute Coronary Syndrome / Myocardial Infarction

• Supraphysiologic testosterone increases thrombotic risk through dose-dependent elevations in hemoglobin/hematocrit and adverse lipid changes (decreased HDL cholesterol) 3
• Trenbolone acetate has 3-fold greater androgenic activity than testosterone, amplifying all cardiovascular risks 2
• Case reports document acute ST-elevation MI in patients using supraphysiologic intramuscular testosterone with traditional risk factors 4
• Immediate workup: ECG, troponin, emergent cardiology consultation

2. Polycythemia with Hyperviscosity Syndrome

• Testosterone stimulates erythropoiesis in a dose-dependent manner, with supraphysiologic doses causing pathologic elevation in hematocrit 1
• Increased blood viscosity from polycythemia aggravates vascular disease in coronary, cerebrovascular, and peripheral circulation 1
• Polycythemia increases stroke and thrombosis risk, particularly with underlying cardiac disease 3
• The combination of high-dose testosterone and resultant polycythemia likely contributed to cardiovascular events in documented cases 4
• Immediate workup: CBC with differential, hematocrit, hemoglobin, peripheral smear

3. Pulmonary Embolism

• Supraphysiologic anabolic steroids are directly associated with pulmonary embolism as a recognized cardiovascular complication 4
• Polycythemia-induced hypercoagulability compounds thrombotic risk 3, 4
• The American Thoracic Society explicitly warns of increased thrombotic risk with testosterone levels above physiologic range 3
• Immediate workup: D-dimer, CT pulmonary angiography, lower extremity Doppler if indicated

4. Heart Failure / Cardiomyopathy

• Cardiomyopathy is a documented complication of supraphysiologic anabolic steroid use 4
• Hypertension commonly develops with these agents, contributing to cardiac remodeling 4
• Increased lean muscle mass (6% increase in Phase 1 of TRT studies) increases cardiac workload 5
• Workup: BNP/NT-proBNP, echocardiogram, chest X-ray

5. Sleep Apnea (Exacerbated or New-Onset)

• Sleep apnea may be exacerbated or newly develop with higher parenteral testosterone doses through central mechanisms rather than anatomical changes 3
• The New England Journal of Medicine lists sleep apnea as a respiratory risk of testosterone therapy 1
• Chronic hypoxemia from sleep apnea presents as exertional dyspnea
• Workup: Overnight oximetry, polysomnography referral, assessment for daytime somnolence

Critical Clinical Pitfalls

• Do not assume "just deconditioning" – the cardiovascular event rate is 7-fold higher in testosterone users, and these are supraphysiologic doses 3

• Do not delay cardiac evaluation – acute MI and PE are immediately life-threatening and well-documented with these agents 4

• Check hematocrit urgently – polycythemia at these doses is expected, not incidental, and directly increases mortality through hyperviscosity 1, 3

• Recognize trenbolone amplifies all testosterone risks by approximately 3-fold due to its greater androgenic potency 2

• The combination of 400 mg testosterone weekly plus 150 mg trenbolone weekly represents an effective androgenic load equivalent to approximately 850 mg testosterone weekly (400 + [150 × 3]), far exceeding the 600 mg/week threshold where adverse effects are documented 1, 2