No heart-related essay on athletes would be complete without mentioning performance-enhancing drugs. No longer are these agents confined to professional athletes. Numerous reports in the media have documented the use of anabolic steroids, erythropoietic stimulants (EPO), insulin, human growth hormone and pseudo-ephedrine in amateur athletes. Few scientific studies have been done, as finding athletes who admit to taking illegal substances is challenging, but it is well known that all of these drugs have potentially negative effects on the heart. I’m not pointing fingers here; the authors of the Circulation review, along with most reviews on the athletic heart mention performance-enhancing drugs.