Rich Piana died at age 46 after collapsing at home and spending two weeks in a medically-induced coma. His autopsy revealed significant heart disease, including an enlarged heart and liver weighing more than twice the average adult male's, as well as mild atherosclerotic disease (hardening of the arteries). However, the exact cause of death was officially ruled as "unknown" because toxicology specimens were discarded by the hospital, preventing a full analysis. These findings suggest his steroid use, which he openly admitted to, likely contributed to his enlarged organs and heart disease, which may have led to cardiac arrest. Prior to collapsing, he showed warning signs like shortness of breath and nausea. His death was ultimately linked to heart complications potentially exacerbated by long-term anabolic steroid use, but no definitive cause could be established due to incomplete toxicology testing.