Walk-in clinics offer convenience and occasionally good medical advice, assuming you survive the aerosolized spray of contagions saturating the waiting room. What walk-in clinics do not offer is a substitute for preventative health or primary care.

This ‘Walk-In Clinic’ column is a collection of questions and experiences encountered by a number of physicians who have treated bodybuilders, athletes and gym rats, using performance-enhancing drugs (PED). Any identifying information has been deleted and details generalized to maintain the confidential nature of the relationship.

The ‘Walk-In Clinic’ is not designed to provide medical advice or guidance to its readers. It is a representation of problems and questions that PED users ask doctors, physician assistants, clinic nurses, athletic trainers, coaches and pharmacists. The responses do not come from the perspective of hardcore drug users, but health professionals who attempt to understand the drive to excel that causes people to take risks.

This column is not designed to and does not provide medical advice, professional diagnosis, opinion, treatment or services to any individual. It provides general information for educational purposes only. The information provided in this column is not a substitute for medical or professional care, and readers should not use the information in place of a visit, call consultation or the advice of one’s personal physician or other health care provider. Contributors are not liable or responsible for any advice, course of treatment, diagnosis or any other information, services or product obtained through this column.

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Medical information changes constantly. Therefore, the information in this column or on the linked websites should not be considered current, complete or exhaustive, nor should you rely on such information to recommend a course of treatment for you or any other individual. Reliance on any information provided in this column or any linked websites is solely at your own risk.

Can steroids cause a heart attack immediately? I got real short of breath and kept coughing just after injecting Equipoise into my right glute. It went away, but since everyone says steroids cause heart attacks, I am worried. I am only 23. I am stacking Equipoise with Winstrol tabs. The Equipoise is only 50 mg/ml, so I have to inject 3 cc twice a week and take six tabs a day. The Winstrol is 2 mg tabs.

Sometimes a patient comes in and behind the professional façade, the physician wants to slap him or her in the face with a strong dose of reality. This is one of those times. If you ever think you are having a heart attack, you get to the emergency room immediately. Don’t drive yourself; call an ambulance if you have to. Don’t go to a convenience clinic, get to an emergency room. The convenience clinic will just call an ambulance in most cases. The biggest determinant of survival and recovery is time-to-treatment for both heart attacks and strokes. The American Heart Association provides a brief presentation on the signs of heart attack and stroke on their website at http://www.americanheart.org/presenter.jhtml?identifier=3053. Everyone should take a moment to read this and consider the advice— it could save a life.

You might have noticed that shortness of breath was one of the symptoms of a possible heart attack. It is impossible to tell over an e-mail if you suffered a heart attack, particularly with the limited information given. To exclude the presence of a myocardial infarction (heart attack), physicians will monitor the heart rhythm using an EKG and may draw blood for lab tests. There are other equally serious events that may lead to shortness of breath, including but not limited to: pulmonary emboli (blood clots in the lungs’ arteries), asthma, collapsed lung, abnormal heart rhythm, etc.

Clotting events in anabolic steroid users may be under-reported. The circulation (blood flow) may be disturbed by narrowing of the arteries, local clot production, or a clot from another area that breaks off and lodges in a smaller artery. Certain anabolic steroids may increase the risks of these events. Stanozolol (Winstrol) is believed by users to be a very mild anabolic steroid, due to its relatively mild properties in bulking, strength gain or aggression. However, stanozolol has a fairly toxic effect on the liver and cardiovascular health. It affects the blood vessels by lowering HDL (good) cholesterol, which may accelerate plaque formation along the artery walls. If these plaques grow large enough, they can plug up the artery and shut off circulation. However, this rarely occurs at your age (23). More relevant is the possibility of one of these plaques bursting and causing a clot as the artery responds to the damage. Many heart attacks are due to plaque rupture. Again, this is very uncommon at your age.

It is important to ask your parents and grandparents about any family history of clotting problems, as some clotting disorders are genetic. Cases of thrombosis (clotting) related to anabolic steroid use are also in the literature.

You did not mention how long you have been using anabolic steroids, or if you have any problems with needles. Some people get nervous about injections and can have a vagal response that leads to light-headedness or fainting.

There are reports of reactions similar to yours following large volume, oil-based, intramuscular injections, mostly involving drugs other than anabolic steroids. Realize that most injectable anabolic steroids are dissolved in an oil base. Take an equivalent amount of vegetable oil and drop it into a glass of water; notice how the oil and water do not mix. Now, stick a straw into a glass and use the straw to drink the water. What happens when the oil reaches the straw? It does not flow up the straw as well; it might either plug up the straw or if it reaches your mouth, it makes you gag. Blood, more specifically the serum, is mostly water (not counting the red blood cells).

Knowing this, think about what might happen if the needle is not embedded into your gluteus muscle, but instead reaches a vein; the glute, like most muscles, is very vascular, to meet the metabolic demands of exercising muscle. The 3 cc of anabolic steroid-containing oil is injected directly into the bloodstream, instead of forming a slow-release depot in the muscle.

This bubble of oil, if injected into a major vein, can travel right up to the heart, passing through and entering the circulation of the lungs. The oil bubble doesn’t cause any problems until it hits the smaller arterioles and capillaries of the lungs. Just like the oil in the straw, the oil in the capillaries interferes with the local blood flow, causing shortness of breath and coughing until the oil clears and is diluted in the heart and peripheral circulation.

Your symptoms are suggestive of this event, but it is a matter of professional responsibility to tell you that you need to discuss this with your personal doctor. There is no way to rule out other more serious possibilities without a more thorough history, physical exam and diagnostic tests.

This question offers a good opportunity to discuss proper injection technique, to avoid this mishap in the future. When injecting into the muscle, it is important to draw back slightly on the syringe plunger. If bright red blood is pulled back into the syringe, the needle is in a blood vessel. It is necessary to pull the needle back slightly, and re-test (pull back on the plunger again). It is likely that many anabolic steroid users have injected into a blood vessel, but smaller volume injections are much less likely to cause noticeable symptoms.

I can get Clen [clenbuterol] pretty cheap. Why do I have to cycle Clen if I can just keep using more? Can’t I just use blood pressure meds if I get jittery?

This question tells me you follow the ‘more is better’ philosophy and will push the envelope until something goes wrong. Individuals, coaches or parents are happy to ignore signs of drug use, as long as it brings fame or financial reward— but when something goes wrong, they blame the system or the drugs. Lyle Alzado wrongly blamed his brain tumor on his use of anabolic steroids, confusing the issue publicly and hampering efforts toward policy changes regarding clinical use.

A recent interview with former Michigan State standout and NFL lineman Tony Mandarich focused on his anabolic steroid use in college and the fact that he failed to disclose the fact to reporters [gasp], essentially trivializing his confession of years-long abuse of painkillers and alcohol during his relatively unimpressive NFL career. Oddly, there isn’t as much of an uproar of the admitted past drug and/or alcohol use of Presidents George W. Bush, Bill Clinton or Barack Obama. One can only imagine that there’s something in the application for the highest elected office in the most powerful nation that asks about past use of illegal drugs.

Getting back to your question, I will not condone or suggest that the use of clenbuterol in escalated (increasing) amounts is safe or can be managed by abusing another drug to block some of the negative side effects; especially not in the setting of unsupervised self-administration of the drugs. Your e-mail address suggests you are male, so I am assuming you plan to use the clenbuterol for fat loss purposes. Clenbuterol is a potent lipolytic (fat-reducing) agent, but it has the drawback of quick habituation, presumably due to downregulation of the receptors at the level of the muscle cell and fat cell. The anabolic (muscle-building) effects of clenbuterol require much higher concentrations than humans can tolerate.

However, there has been research performed on people undergoing therapy to treat severe congestive heart failure that used very high doses of clenbuterol for several months. In these studies, people who had such poor heart function that they required the placement of mechanical pumping devices were given clenbuterol in escalating doses until they were taking 720 mu grams (micrograms) daily; to prevent dangerous elevations in heart rate, a selective beta-1 antagonist was provided. These patients demonstrated significantly greater lean mass and strength. Not surprisingly, endurance was not improved. Therapeutically, clenbuterol is used at a dose of 40-80 mu grams/day; bodybuilders generally do not exceed 120-160 mu grams/day because they cannot tolerate the side effects.

Though the ‘bodybuilding’ dose of clenbuterol, or even the therapeutic dose may increase fat loss, it does little for muscle gains (lean mass or strength). A follow-up study of similar patients with heart failure showed that an 80 mu grams/day dose did not improve strength, though the lean-to-fat ratio improved in the clenbuterol group.

If the day comes when people can be monitored by a health professional, then there might be a role for using a beta-1 antagonist in combination with clenbuterol in muscle-wasting disorders. It is highly unlikely you will live to see the day the FDA allows clenbuterol and beta-1 blockers to promote muscle hypertrophy.